s
363.88;
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1988
State plan for
Montana's special
supplemental food pro-
gram for women, infants
and children (WIC)
State plan lot Montana's special supplem
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AUG 1 2 J987
1988 STATE PLAN
for
MONTANA'S SPECIAL SUPPLEMENTAL
FOOD PROGRAM FOP. WOMEN, INFANTS
AND CHILDREN fWICl
MONTANA DEPARTMENT OF HEALTH AND
ENVIRONMENTAL SCIENCES,
John J. Drynan, M.D., Director
1988 MONTANA WIC STATE PLAN
Table of Contents
INTRODUCTION
SECTION I.
SECTION II.
SECTION III.
SECTION IV.
SECTION V.
SECTION VI.
SECTION VII.
SECTION VIII.
SECTION IX.
SECTION X.
SECTION XI.
SECTION XII.
SECTION XIII.
SECTION XIV.
SECTION XV.
SECTION XVI.
SECTION XVII.
SECTION XVIII.
Goals and Objectives
Budget
Participation
State Agency Resources
Affirmative Action Plan
Migrant Farmworkers and Indians
Availability of Program Benefits
Coordination with Health Services and Other Programs
Nutrition Education Goals and Action Plans
Manual
Financial Management System
Distribution of Administrative Funds
Food Delivery System
Dual Participation
Civil Rights
Fair Hearings
Targeting
Pol icy Statements
Figure 1 - Organizational Chart
APPENDICES
APPENDIX 1: Definitions Used in the WIC Plan
APPENDIX 2: Affirmative Action Ranking and Projected WIC Caseload for FY 87
APPENDIX 3
APPENDIX 4
APPENDIX 5
APPENDIX 6
APPENDIX 7
APPENDIX 8
APPENDIX 9
APPENDIX 10
APPENDIX 11
APPENDIX 12
APPENDIX 13
APPENDIX. 14
APPENDIX 15
Application Packet for Local Agencies
Description and Maps of Local Agencies
Conducting Vendor Investigations/Vendor Monitoring
Program Buy Packet
Vendor Monitoring Checklist
Violations Summary
Letter From DHES Assuring Title VI Compliance
Nutrition Education Expenditures
MIC Food List
WIC Participant Survey
Model Agreement
Model Satellite Agreement
Assurance that Adequate Food Vendors Serve An Area
INTRODUCTION
INTRODUCTION
c
1988 Montana State Plan Purpose
1. To provide an action plan with defined goals and objectives for
operation and administration of the WIC Proaram during Federal
Fiscal Year 1988.
2. To demonstrate compliance with federal law and U.S.D.A. Regulations
applicable to the WIC Program.
3. To inform the public and local agencies of WIC program components
and operations, and provide a mechanism for their input into program
administration.
The WIC Program
1. Description: The Special Supplemental Food Program provides low
income, pregnant, postpartum, and lactating women, infants and
children up to age five, at nutritional risk, with:
a. Nutrition assessment, education and counseling to improve
eating behaviors and reduce nutritional problems.
b. Selected foods to supplement diets lacking in nutrients needed
during this critical time of growth and development.
c. Access to preventive health programs and referral to private
and public health providers.
2. Authority for WIC: WIC is administered by the United States Depart-
ment of Agriculture (USDA) under Public Law 95-627, Child Nutrition
Act of 1966. Current regulations were issued July 27, 1979 with the
exception of food package regulations which follow Section 246-8 of
August 26, 1977. Revisions of these regulations were published
February 13, 1985.
3. Congressional Intent: Public Law 95-627 defines the purpose of WIC:
"Congress finds that substantial numbers of pregnant, postpartum and
breastfeeding women, infants and children from families with inade-
quate income are at special risk with respect to their physical and
mental health by reason of inadequate nutrition or health care or
both. The purpose of WIC is to provide supplemental foods and
nutrition education through local agencies to eligible persons. The
program shall serve as an adjunct to good health care during crit-
ical times of growth and development in order to prevent the occur-
rence of health problems and improve the health status of these
persons."
4. Organizational Overview: Funds for food and administrative costs
are funneled from USDA, Food and Nutrition Service (FNS), to the
State Agency, which in Montana is the State Department of Health and
Environmental Sciences, Family/Maternal and Child Health Bureau, WIC
Program. The State WIC Agency makes grants to local programs which
provide direct services to the participants. Responsibilities for
delivery of the services is divided into three levels:
(
a. Responsibilities of Local Agencies: Local Agencies hire staff,
conduct outreach, certify program applicants, issue food
vouchers to participants, enter into agreements with and
provide training to vendors, prepare annual nutrition health
plans, provide nutrition services, interpret State policies and
procedures, establish local agency policies, and provide
certain minimum health care services to all program partici-
pants.
b. Responsibilities of the State Agency: These include provision
of funding to Local Agencies through the contracting process,
maintaining the food delivery system and fiscal responsibility,
interpretation of USDA regulations, policy making and develop-
ment of procedures for program operation, monitoring, technical
assistance and training for Local Agencies in nutrition and
administration, and writing the State Plan.
c. Responsibilities of USDA's Regional Office; Denver, Colorado:
The Denver office performs management evaluations on state and
local levels to determine compliance with federal regulations,
FNS guidelines, and the Montana State Plan. They provide
technical assistance and act as a clearinghouse for USDA policy
and information, and distribute monies to the state agencies in
their region via published funding formulas.
5. Overview of Local Program operations: The potential participant
applies for program benefits and is determined eligible or ineligi-
ble based on information she/he provides regarding his/her place of
residence, income and nutritional status. If eligible, vouchers are
given each month for specific food items allowed on the program and
which have been prescribed for their nutritional needs. Nutrition
care is provided during the certification period according to a
written plan for the individual or family. Participants are re-
ferred to private medical practitioners, well child clinics, commu-
nity agencies or programs as appropriate. At periodic intervals,
participants reapply for certification.
C. WIC In Montana
The Montana WIC Program began in 1974, with two pilot projects on the Fort Peck
and Northern Cheyenne Reservations. By the end of 1974, approximately 800
women, infants and children were receiving program benefits monthly. Total
program funds at that time were approximately $120,000. In the beginning of
1976, the caseload had reached 7,900 monthly in 10 counties and 7 Reservations.
By April of 1978, the caseload had risen to 12,200 monthly, and in addition to
the 7 Indian Reservations, participants in 39 counties were served by the WIC
program. ■
Currently, about 13,500 clients per month receive WIC benefits through thirty-
one local agencies (including seven Indian reservations) in 40 counties.
SECTION I
GOALS AND OBJECTIVES
7 CFR 246.4(a)(1)
'
A. Mission: To provide low income, pregnant, postpartum, and lactating
women, infants, and children up to age five, at nutritional risk, with:
a. Nutrition education and counseling, intervention, referral and
follow-up on identified risks to improve eating behaviors and reduce
or eliminate nutritional problems.
b. Selected foods to supplement diets lacking in nutrients needed
during this critical time of growth and development.
c. Access to preventive health programs and referral and follow-up to
private and public health providers.
B. Goal : To improve trans-cultural awareness by state agency staff.
1. Objective: By November 30, 1987, all state agency staff will have
attended at least one educational session which provides information
about Native American cultures in Montana.
2. Objective: By February 28, 1988, the WIC Program Coordinator will
have completed a needs assessment of all Montana tribes with respect
to WIC Program operations utilizing the expertise of Tribal Health
Directors to identify and maintain important cultural health care
perspectives.
3. Objective: By November 30, 1987, all agencies will have been
provided with resources, information and references regarding
cross-cultural counseling and consultation.
C. Goal : To improve basic Program operations by making food instrument
issuance more efficient, cost-effective and compatible with
data-gathering requirements.
1. Objective: By September 30, 1987, the WIC Program Coordinator will
have identified alternative methods of evaluating current procedures
for food instrument issuance.
2. Objective: By October 31, 1987, the WIC Program Coordinator will
have implemented the evaluation of current procedures.
3. Objective: By March 1, 1988, an alternative method of program
operations and food instrument issuance will have been identified
for implementation in SFY 1989.
D. Goal : To assure the cost-effectiveness of administration and management
of the Montana WIC Program.
1. Objective: By September 15, 1987, the WIC Program Coordinator will
have identified services similar to WIC provided by Departments of
Montana State government (to include, but not be limited to Social
and Rehabilitative Services, Health and Environmental Sciences, and
Labor and Industry) and areas therein suitable for coordination.
s
2. Objective: By September 30, 1987, the WIC Program Coordinator will
have drafted a plan for coordination of WIC services with other
agencies of state government which will emphasize reducing
administrative costs and maximizing benefits to individuals
participating in the Montana WIC Program.
Goal : To optimize the money used to provide WIC benefits to eligible
participants.
1. Objective: ByAugust 31, 1987, methodologies for containing the cost
of infant formula used in the Tennessee, South Carolina, Oregon and
Wyoming WIC Programs will be received for review by Montana WIC
Program staff.
2. Objective: By December 31, 1987, a process for containing the cost
of infant formula will be identified for use in Montana and a plan
for implementation of the process written.
3. Objective: By June 1, 1988, a review of competitive pricing
methodology for WIC foods other than infant formula will be
completed by Montana WIC Program staff.
Goal : To assure consistent application of program procedures and pol-
icies by local agencies.
1. Objective: By December 1, 1987, the WIC Program Coordinator will
have prepared and tested a written tool designed to reduce error
rates in WIC operations by assuring training of those persons issued
Authorized Signature Cards.
2. Objective: By January 31, 1988, state rules for the operation of
WIC in Montana will be adopted.
1-2
I
*\
SECTION II
BUDGET
7 CFR 246.4(a)(2)
NOTE:
This information will be completed and made available within 30 days
of notice of the FFY 88 grant award.
♦v
II-l
BLANK PAGE FOR WIC ADMINISTRATIVE BUDGET FORM
1 1-2
BLANK PAGE FOR MONTANA WIC PROGRAM FOOD BUDGET FORM
I
5
II-3
SECTION III
PARTICIPATION
7 CFR 246.4(a)(3)
•
■
SECTION IV
STATE AGENCY STAFFING PATTERN
7 CFR 246.4(a)(4)
IV. STATE AGENCY STAFFING PATTERN
A. Organizational Structure: The MIC Program is a program unit within
the Family/Maternal and Child Health Bureau, whose Bureau Chief
reports to the Health Services Division Administrator, Department of
Health and Environmental Sciences. The Director of SDHES reports to
the Governor. Figure 1 is an organizational chart for SDHES.
B. MIC Staff:
a. Program Manager: 1.0 FTE (Full Time Equivalent), currently
filled by David L. Thomas.
Position Requirements: Master's Degree in Business, Nutrition,
Public Administration or Public Health -- preferably with major
work in health, human services, administration or nutrition.
Responsibilities: Overall program manaoement includes plan-
ning, policy development, organization, evaluation; allocates
funds to Local Agencies; monitor Local Agencies for compliance.
?. Administrative Officer: 1.0 FTE, currently filled by Nolan
Mai strom.
Position Requirements: Bachelor's Degree in Business, Account-
ing or related field; supervisory and administrative experi-
ence.
Responsibilities: Maintains data processing systems; develops
budget and does fiscal management, assists Program Manager in
performance of duties; monitors Local Agencies for compliance;
provides technical assistance to Local Agencies in administra-
tive procedures, vendor compliance.
3. Administrative Officer: 1.0 FTE, currently filled by Judith M.
Wright.
Position Requirements: Bachelor's Degree in Business, Account-
ing or related field; supervisory and administrative experience
Responsibilities: Maintains certification data system; devel-
ops budget and does fiscal management, assists Proqrarn Manager
in performance of duties; monitors Local Agencies for compli-
ance; provides technical assistance to Local Agencies in
administrative procedures, vendor compliance.
4. Administrative Assistant I: 1.0 FTE, currently filled bv Diana
Watson.
Position Responsibilities: Orders drafts; fills orders from
Local Agencies; coordinates workshop and travel arrangements;
reviews redeemed food instruments;; handles correspondence,
phone calls and vendor data monitoring.
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IV-l
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e. administrative Assistant II: 1.0 FTE, currently filled by V
Patricia Buck.
Position Responsibilities: Reviews monthly expenditure reports
and vendor invoices from Local Agencies; reviews and corrects
data processing data; maintains equipment inventory; prepares
monthly financial reports for USDA.
f. Administrative Clerk II: 1.0 FTE, currently filled by Beth
Holcomb.
Position Responsibilities: Maintains file system for vouchers;
reviews log sheets for accuracy; mails computer printouts to
Local Agencies; handles stop payments, and performs other
duties assigned by the Program Manager.
g. Data Entry Operator III: 1.0 FTE, currently vacant.
Position Responsibilities: Process daily Certification
Records, Log Sheets and data for special projects; key enter
data; verify and correct data; provide problem-solving
assistance to WIC Input/Output (I/O) controller and local
agency staff.
Other Division Staff:
a. Nutritionist: 1.0 FTE, currently filled by SeAnne Safaii.
Position Requirements: Master's Degree in Nutrition; two years
experience in public health nutrition. Must be a registered
dietitian.
Responsibilities: Assigned full-time to WIC; develops and
evaluates nutrition and health services of the WIC Program,
including provision of training and technical assistance to
local agencies; plan and develop nutrition policies and proce-
dures; monitors local agencies for compliance, and develops
standards of nutrition care to be delivered under the Program.
b. Nutritionist: 1.0 FTE, currently filled by Pat Hennessey.
Position Requirements: Master's Degree in Nutrition; two years
experience in public health nutrition. Must be a registered
dietitian.
Responsibilities: Assigned full-time to WIC; develops and
evaluates nutrition and health services of the WIC Program,
including provision of training and technical assistance to
local agencies; plan and develop nutrition policies and proce-
dures; monitors local agencies for compliance, and develops
standards of nutrition care to be delivered under the Program.
Others : Consultation is provided by other Division staff as needed,
including the Chief Nutritionist, Family/Maternal and Child Health i<*i
Bureau Chief, Health Planning and Resource Development Bureau and
Preventive Health Services Bureau.
IV-3
SECTION V
AFFIRMATIVE ACTION PLAN
7 CFR 246.4(a)(5)
ESTABLISHMENT OF AFFIRMATIVE ACTION PLAN
A. The Affirmative Action Plan for FY 88 has been based on 1980 U.S.
census data and updated (1985) data on low birth weight infants from
the Montana Department of Health and Environmental Sciences (SDHES).
Actual monthly caseload by priority reflects the month of March,
1987. The number of eligible participants for each local agency is
listed in Appendix 2: Affirmative Action Ranking and Projected WIC
Caseload for FY 88.
B. Description of ranking system: To establish the ranking, the
following criteria were used:
a. Incidence of low birth weight infants (1980-1985).
b. Percentage of population (women-children under age 5^ at 185%
of poverty or less (1980 census1!.
c. Minority populations (1980 census).
Discussion
Montana has 56 counties and 7 Indian Reservations for a total of 63
possible local agency units. The Tribal WIC Programs on the reservations
cover 11 counties and serve both on and off-reservation Indians in their
respective areas.
Data for criteria (a) was based on a study done by of the Bureau of
Records and Statistics, SDHES, entitled "Low birth weight by county of
residence and race of mother for 1980-1985." The data in this study was
broken down by county, and within county, by race - white, Indian, and
other. The DHES study supplied the latest figures available on the
number of low birth weight babies over a five-year period in the State.
The data used in this study are statistically reliable. The statistician
employed by the Records and Statistics Bureau of SDHES reviewed the
Affirmative Action Plan for appropriate statistical technique and analy-
sis. Data presented included the 56 counties and 7 Indian Reservations.
Figures for Indian Health Service Units, however, had to be extrapolated
from the county figures (1980 census). Figures for Indians in Big Horn,
Blaine, Flathead, Glacier, Hill, Lake, Missoula, Phillips, Pondera,
Roosevelt, Rosebud, Sanders and Valley Counties were therefore pulled
from the totals for those counties and used to establish data for the
reservations .
C. Criteria
Criterion (a) Ranking for the incidence of low birth weight babies
was based on SDHES statistics for 1980-1985 as previously
mentioned. Counties and reservations with the highest inci-
dence were given the highest ranking.
*•
V-l
Criterion (b) Population at 185% of poverty or less was determined
from income and poverty status data based on 1980 Bureau of
Census statistics for General Social and Economic Characteris-
tics. Income for women and children under 5 at or below 185%
of poverty is used as an indicator for evaluating financial
eligibility throughout Montana. Counties and reservations with
the highest number of financially eligible population were
given the highest ranking.
Criterion (c) Information on minority populations was taken from
1980 census reports. Each county and reservation was ranked by
its minority population as a percentage of the State total.
Areas with the highest percentage were given the highest
ranking.
Anticipated Caseload/Potentially Eligible Persons
The number of potentially eligible persons was obtained by utilizing
census data for children below 185% poverty and number of total
births. These data were inserted into the following formula, as
suggested by the 1988 State Plan Guidance:
[(Total births x 1.25) x % children below 185%] + no. children below
185% equals potentially eligible population.
The Affirmative Action Plan rankings would be used as one tool among
many to assist in the expansion of WIC in Montana, when and if funds
become available.
If funds were available new agencies or satellites would be opened
in descending order from the top in the Plan, with no agency receiv-
ing funds until the eligible agencies above were funded. A Request
for Proposal (RFP) for agencies meeting Program criteria would be
solicited in the area(s) of proposed expansion in accordance with
regulations. Such agencies could include county governments,
hospitals and so forth. The RFP would be advertised in the media
and the State Agency would make direct contact with known eligible
agencies in the area. Applicants would be assisted in the applica-
tion process as outlined in Appendix 4, "Application Process," and
selected in accordance with 7 CFR 246.5(d).
The Affirmative Action Plan rankings may be utilized as a tool to
distribute administrative funds to agencies should a reduction in
funds occur.
If administrative funds were reduced, those agencies would be
terminated in ascending order from the bottom o^ the list.
The Affirmative Action Plan rankings may be used to redistribute
caseloads between local agencies relative to (a) and (b) above, but
not for the specific manipulation of caseloads.
V-2
H. The Affirmative Action rankings will never be used outside the
context of the rural nature of our State and (relatively^ sparse
population. Any decision regarding expansion or termination of
agencies will utilize the Affirmative Action Plan as well as dis-
tances to available health care, economic condition of the area and
other factors as appropriate.
I. The Montana WIC Program serves Priorities I-V (Ref. Policy #84-6).
J. There are no CSFP programs in Montana.
K. Process for Application of Agencies Interested in Operating a WIC
Program
1. Initial contact between agency and DHES.
2. Application Package (Appendix 3) sent to applicant within five
calendar days of initial contact.
3. Within 15 calendar days after receipt of an incomplete applica-
tion, written notification to the applicant agency of the addi-
tional information needed will be provided.
4. Within 30 calendar days after receipt of a complete applica-
tion, the applicant shall be notified in writing of approval or
disapproval of its application.
5. When an application is disapproved, the applicant agency shall
be notified of its right to appeal as set forth in 7 CFR
246.18, and of the reasons for disapproval.
6. When an agency submits an application and there are no funds to
serve the area, the applicant shall be notified within 30
calendar days of receipt of the application (whether incomplete
or not) that no funds are available.
The application shall be returned to the applicant, and the
name and address of the applicant agency shall be retained by
the State Agency.
7. When funds are available and an application is approved, the
state agency shall schedule an on-site visit to the agency and
assist in the set-up of operational procedures as soon as
practical after approval, but not less than 30 calendar days
post-approval .
L. The review criteria for selection of local agencies to administer
the WIC Program will include, but not be limited to the following
factors:
1. The applicant's position in the Montana WIC Affirmative Action
Plan.
»
V-3
?.. Adherence to 7 CFR 246.5. f Priority A: A public or private
non-profit health agency that provides ongoing routine
) pediatric and obstetric care and administrative services;
Priority B: A public or private non-profit health or human
service agency that will enter into a written agreement with
another agency for either ongoing routine pediatric and
obstetric care or administrative services: Priority C: A
public or private non- profit health agency that will enter
into a written agreement with private physicians, licensed by
the State, in order to provide ongoing routine pediatric and
obstetric care to a specific category of partici pants (women,
infants or children); Priority D: A private or non-profit
human service agency that will enter into a written agreement
with private physicians, licensed by the State, to provide
ongoing routine pediatric and obstetric care; Priority E: A
public or private non-profit heaTth or human service agency
that will provide ongoing routine pediatric and obstetric care
through referral to a health provider.^
3. The applicant's projected ability to meet WIC Program
regulations and State policies and procedures
4. The applicant's history of performance in other programs and in
administering similar public health services.
5. The applicant's plan for providing linkages with appropriate
health care providers.
6. The applicant's ability to make the Program accessible to
participants.
7. The applicant's projected cost of operations.
8. The applicant's financial integrity and solvency as
demonstrated by independent audits.
V-4
SECTION VI
MIGRANT FARMWORKERS AND INDIANS
7 CFR 246.4(a)(6)
VI. MIGRANT FARMWORKERS AND INDIANS
A. Responsibility for the provision of program benefits to migrant
farmworkers is delegated to local agencies. Any special clinics
(such as evenings) or needs (such as interpreters') are to be ar-
ranged by local clinics in accordance with their own community
needs, the season of work, and local representatives of other
service agencies. The State Agency offers technical assistance upon
request.
B. All seven Indian reservations in Montana contract with DHES for the
provision of WIC services and benefits.
VI-1
SECTION VII
AVAILABILITY OF PROGRAM BENEFITS
7 CFR 246.4(a)(7)
VII. OUTREACH AND REFERRAL
A. General Public Including Potential WIC Participants
1. State WIC Agency Responsibilities:
a. Develop annual press release statements and public service
announcements for Local Agencies to send to newspapers ,
radio and television stations in their areas at least once
annually, or more often as needed.
Press releases and announcements must include name and
address of the Local Agency, eligibility criteria and
information on program benefits which include supplemental
foods, nutrition education, and access to on-going health
care. In areas where maximum case load has been reached,
press releases will focus on maintenance of caseload and
reaching high-risk participants.
b. Prepare and distribute posters and brochures to local
agencies for use in enlisting new WIC clients.
c. Outreach to migrant farmworkers is described in Section VI
of the State Plan.
2. Local WIC Agency Responsibilities:
a. Send press releases and public service announcements to
local media at least once annually.
b. Display WIC posters and pamphlets in waiting rooms,
community agency offices, etc.
c. Show WIC slide show "WIC in Montana" to interested groups.
d. Keep on file documented efforts of outreach and referral
for review by the State monitoring team.
B. Potential County Programs
If and when expansion monies are available, the State WIC Agency
will visit areas that do not have WIC programs but are interested in
starting one or becoming a satellite of a larger program nearby.
C. Health Professionals (Physicians, Dietitians, Nurses, Social Work-
ers, etc.)
1. State WIC Agency Responsibilities:
a. Distribute WIC brochures, posters, standard referral forms
and educational materials on infant, maternal and child
nutrition to the Local Agencies to give to health profes-
sionals in their communities.
c
VII-1
)
b. Inform health professionals of the WIC program at various
meetings and workshops (e.g., regional workshops for
nurses) .
c. Encourage coordination of health services in Local Agen-
cies by developing forms that facilitate communication;
encourage Local Agencies to combine patient records,
coordinate clinic days, etc.
d. Encourage Local Agencies to use assessment information
from physicians by providing forms that make this possi-
ble.
e. Monitor Local Agency's efforts in outreach and referrals
with health professionals.
2. Local MIC Agency Responsibilities:
a. Distribute materials to local physicians, dietitians,
nurses and other health professionals. These materials
include income guidelines and nutritional risk criteria
for referral of clients to WIC, as well as information on
the WIC program.
b. Offer nutrition training to health professionals who
desire and request it.
c. Follow-up on referrals made to WIC by health profession-
als.
d. Inform health professionals in special counseling programs
such as alcohol and drug abuse, and family planning
centers about WIC and refer WIC participants to these
services where appropriate.
e. Refer WIC participants to health professionals for on-
going and routine pediatric and obstetric care. This
includes private medical practitioners and well child
clinics which provide immunizations, infant and child
care, prenatal and postpartum examinations, etc.
f. Exchange care plans whenever necessary and appropriate.
g. Keep copies of referrals made in WIC participants' fold-
ers.
Referral Coordination:
Each Local Agency must identify their referral network by problem
area (e.g. educational, economic, medical, social, etc.) in their
nutrition education plan which is submitted annually to the State
Agency.
The State WIC agency has identified and described in the Policies
and Procedures Manual methods by which WIC services should be
coordinated with existing health and social service agency programs.
VII-2
Contacts With Specific Groups:
1. General Public The State Agency has available public service
announcements, brochures, posters, etc. which can be used by
Local Agencies in their outreach campaigns.
2. Health Professionals The State Agency is using a Documentation
of Prenatal Care Form. This form facilitates exchange of
information between physicians and WIC projects. Local
Agencies develop their own referral systems.
3. County Commissioners Local and State Agency personnel keep
county commissioners informed of WIC by sharing results of the
annual monitoring process.
4. Wholesale Grocers The State Agency has made available to all
chain stores a slide/tape presentation for new employee orien-
tation.
5. Retail Grocers Procedures for monitoring and education of
vendors are found in the Policies and Procedures Manual.
6. Community Agencies Community organizations and agencies will
be invited to future WIC workshops as they have been in the
past. Contacts have been made with migrant organizations
throughout the State, and Local Agencies have been encouraged
to work with them.
Ongoing efforts are being made to increase the participation of
off- reservation Indians in existing WIC programs.
7. Vendors
a. Local Agencies are encouraged to involve vendors in
nutrition information demonstrations or campaigns.
8. Health Officers, Indian Health Service Unit Directors, etc.
a. Whenever possible, State Agency personnel visit these
persons during the annual monitoring.
b. Local Agency staff is encouraged to make visits to these
groups at least once annually to inform them of WIC
successes in their area.
WIC Healthy Mothers/Healthy Babies Coalition
1. The Montana Healthy Mothers/Healthy Babies Coalition is com-
posed of more than 60 organizations and agencies that has the
stated purpose of working toward improving the quality and
scope of public and professional education on maternal, peri-
natal, and infant concerns. Their common goals are:
a. To supply information that encourages healthy habits for
pregnant women and women planning pregnancy.
VII-3
c
\
b. To motivate pregnant women to prevent specific health
risks and educate them to the importance of taking respon-
sibility for healthy childbearing.
c. To increase understanding among men of the supportive role
they play in pregnancy and infant care.
2. The mission of the Coalition is to identify and reduce the risk
of maternal, perinatal and infant mortality, morbidity and
disabil ity.
Truly, WIC has been a leader in this mission since the Program
was initiated a decade ago.
Now the hope is that, through the broadened constituency of the
Healthy Mothers/Healthy Babies Coalition, there will be greater
support of the WIC nutrition education goals. It will be WIC's
continued commitment to strengthen the health network and
upgrade standards of nutrition care by promoting the exchange
of pertinent health information with the primary health provid-
ers, the physicians. Additionally, cooperation with other
involved health care providers should result in improved
qual ity of care.
VII-4
(«
(
SECTION VIII
COORDINATION WITH HEALTH SERVICES AND OTHER PROGRAMS
7 CFR 246.4(a)(8)
VIII. COORDINATION WITH SPECIAL COUNSELING SERVICES AND OTHER PROGRAMS (
NOTE: These include but are not limited to:
Health and medical organizations; Family Planning, Dental, Alcohol and
Drug Abuse Programs; Hospitals; Clinics including Well-Child and Early
and Periodic Screening, Diagnosis and Treatment Programs; MCH Programs,
Welfare Programs, including Aid to Families with Dependent Children
(AFDC); Food Stamps; unemployment offices; social service agencies;
farmworker organizations (with special emphasis on migrants); Indian
Tribal Organizations and agencies contacting off-reservation or landless
Indians; religious and community organizations in low income areas such
as community action agencies, Headstart, Expanded Foods and Nutrition
Education Program (EFNEP); schools; child abuse teams; etc..
A. State WIC Agency Responsibilities:
(1) Distribute WIC brochures, posters and referral forms to Local
Agencies.
(2) Offer training to community agencies who desire and request it.
(3) Invite interested agencies (including MCH programs^ to State
WIC workshops.
(4) Inform State Food Stamp Program and AFDC Program of WIC regu-
lations regarding referrals; learn what materials and training .
are available from those programs for the WIC Program. Get '
local addresses of the above two programs to distribute to
local WIC offices. If necessary, do this annually by letter.
(5) Contact Montana Migrant and Seasonal Farmworkers Council
located at 2406 6th Avenue North, Billings, Montana 59102,
annually to determine appropriate agencies to contact for
outreach and referral. Provide the council with names, ad-
dresses, phone numbers and operation hours of all WIC clinics.
Refer this information to local WIC agencies and encourage
contact with the Migrant Council in their area.
(6) Contact state MCH programs and provide information on Program
operations.
(7) Monitor Local Agencies for compliance with outreach and refer-
ral procedures.
(8) Continue to investigate various alternatives for serving
off-reservation Indians more effectively.
(9) All outreach materials will contain, or have attached to them,
a listing of locations and telephone numbers of all local
agencies as well as an attachment which describes the current
income guidelines and nutritional risk criteria.
VIII-1
B. Local WIC Agency Responsibilities:
(1) Distribute materials to community agencies along with income
guidelines and nutritional risk guidelines. All local agencies
will provide a list of locations and telephone numbers of other
Montana WIC agencies, along with income guidelines and nutri-
tion risk criteria whenever they distribute such brochures,
posters and forms.
(2) Include specific ideas for outreach and referral in the local
agency Nutrition Services Plan and indicate which agencies will
be contacted.
(3) Document outreach and referral done; place a copy of the
standardized referral form in client's folder. Share care
plans where appropriate.
(4) Inform WIC participants of the Food Stamp Program and AFDC if
they appear eligible. These two programs should be contacted
annually and addresses and phone numbers of these local pro-
grams should be made available to WIC recipients. Local
Agencies shall request Food Stamp materials from Food Stamp
offices and make them available to WIC participants. Materials
from community programs should be posted on bulletin boards in
WIC offices along with names, addresses and phone numbers. The
Food Stamp Program and AFDC offices should have addresses,
phone numbers, and operation hours of all WIC sites.
(5) Work with community agencies to coordinate whenever possible
WIC clinic hours, nutrition education programs, locations
and/or medical or nutritional assessments when serving the same
population. Strive for close proximity of location.
(6) Make special efforts to reach migrant farmworker populations.
(7) In areas where there are non-reservation or landless Indians,
attempts will be made to inform these people of the WIC Program
directly and/or through agencies that have contact with them.
(8) Follow-up on referrals made.
VIII-2
t
SECTION IX
NUTRITION EDUCATION GOALS AND ACTION PLANS
7 CFR 246.4(a)(9)
1987 MONTANA STATE WIC NUTRITION HEALTH GOALS AND OBJECTIVES £
GOAL: To reduce the occurrence of low birthweight among infants born to women
in Montana by reducing the occurrence of low birthweight in the WIC target
population.
Objectives:
1. By October 1, 1988, follow up training as necessary will have been
provided and there will be common understanding by the local WIC Nutri-
tion Education staff of the identification, certification, intervention,
referral, follow up, and reporting of the data of the high-risk, pregnant
woman.
2. By June 15, 1988, each local WIC agency will have established a system
for referral and follow-up to ensure on-going medical care of the preg-
nant woman.
3. By June 15, 1988, written standards of practice and written protocols for
use in counseling in specific nutrition related conditions will be com-
pleted and will be the standard in all Montana WIC clinics.
4. By June 1, 1988, the Montana WIC Program will have coordinated it's needs
for smoking cessation programs with other health programs.
GOAL : To reduce the occurrence of Baby Bottle Tooth Decay among infants and ,
young children born to women in Montana by reducing the occurrence of Baby '*
Bottle Tooth Decay in the WIC target population.
Objectives:
1. By October 1, 1988, Baby Bottle Tooth Decay educational materials will
have been made available to all involved in nutrition education in WIC.
2. By October 1, 1988, local agency WIC staff will have had follow-up
training in dental screening as part of the assessment and identification
of nutrition problems in the WIC population.
3. By October 1, 1988, state agency the WIC staff will have written stan-
dards of practice and protocols for the identification of those behaviors
and conditions that contribute to Baby Bottle Tooth Decay and for the
counseling, referral and follow-up required.
4. By October 1, 1988, valid data on the extent of the problem of Baby
Bottle Tooth Decay and potential Baby Bottle in the WIC population will
be available.
5. By October 1, 1988, statistics will be available on the successful inter-
vention of Baby Bottle Tooth Decay and Potential Baby Bottle Tooth Decay
in the WIC population and will be made available to the Montana Coalition
of Healthy Mothers, Healthy Babies Subcommittee on Oral Health.
GOAL: To promote breastfeeding in the WIC Target Population and provide educa- C
tion and support so that the infant is breastfed to at least six months of age.
IX-3
Objectives:
1. By October 1, 1988, breastfeeding follow up training will be made avail-
able to all involved in nutrition education in WIC.
2. By October 1, 1988, the state WIC staff will have written standards of
practice and protocols regarding breastfeeding available to all involved
in nutrition education in WIC.
3. By October 1, 1987, breastfeeding resources, materials and references
will have been made available to all involved in nutrition education in
WIC in Montana.
4. By October 1, 1987, breastfeeding will be recognized as the feeding of
choice by the WIC nutrition education staff, by the Montana Dietetic
Association, by the Public Health Nurses, and by others involved in
providing feeding guidance.
5. By October 1, 1987, breastfeeding of the handicapped infant will be
recognized as the feeding choice by Montanans who provide infant nutri-
tion education: the WIC nutrition education staff, the Montana Perinatal
Physicians, the Montana Handicapped Children's Services Program, the
Montana Dietetic Association, Extension Services.
GOAL: To establish standard methods of evaluating the nutrition education
provided to WIC participants.
Objectives:
1. By June 1, 1988, the WIC participant survey will be completed and the
nutrition education needs and wants reviewed. Recommendations and modi-
fications will then be made. This will be a bi-annual project.
2. By October 1, 1988, a system to evaluate nutrition education handouts and
materials (resources), will be in place, as required by the Focus On
Management Nutrition Standards.
IX-4
c
SECTION X
MANUAL
7 CFR 246.4(a)(ll)
TABLE OF CONTENTS
c
Page
1. Introduction
WIC - What Is It X-l
Local Programs: Addresses & Phone Numbers X-3
Map - Local Program Service Areas X-7
2. WIC Regulations X-9
3. Agreement - State and Local Agency X-10
4. Satellite Agreement X-18
Outline •. . . X-18
Agreement - Local Agency and Satellite X-19
5. Application and Certification X-24
Index X-24
6. Food Drafts and Reports X-59
Index X-59 ,
7. Fair Hearing Procedures X-78
Index X-78
8. Vendors X-83
Index X-83
9. Financial Management X-108
Index X-108
10. Monitoring X-129
Index X-129
11. Forms and Pamphlets X-154
Index X-154
12. Complaints X-158
Index X-158
13. Nutrition Education X-160
I
Index X-161
INTRODUCTION
TO
WIC PROCEDURE MANUAL
The WIC Policies and Procedures Manual has been prepared for use by state and
local staff involved in administering the WIC Program. The levels of responsi-
bility are included for each section of the manual to clarify and explain the
duties necessary to successfully implement that particular portion of the WIC
Program.
The policies and procedures herein are subject to change as new information
regarding regulations and guidelines becomes available. As changes occur, they
will be forwarded for addition to the manual. Please send suggested revisions
on clarity or content to the following address:
STATE WIC PROGRAM COORDINATOR
STATE DEPARTMENT OF HEALTH AND
ENVIRONMENTAL SCIENCES
HEALTH SERVICES DIVISION
COGSWELL BUILDING
HELENA, MONTANA 59620
Prepared by:
Montana State WIC Program Staff
Revised February, 1986
WIC - WHAT IS IT? HOW DOES IT WORK?
Purpose
The Special Supplemental Food Program for Women, Infants and Children, better
known as WIC, provides low income pregnant, postpartum and lactating women, and
children to age five, with selected foods to supplement diets lacking in nutri-
ents needed during this critical time of growth and development; education and
counseling to improve eating and food buying habits; and access to preventive
health programs and referral to private and public health providers.
Authority for WIC
Revised WIC regulations were issued February 13, 1985 in conformance with the
Child Nutrition Amendments of 1978 to Section 17 of the Child Nutrition Act of
1966, under Public Law 95-627.
Funds for food and administrative costs are funneled from the United States
Department of Agriculture (USDA), Food and Nutrition Service (FNS), to the state
agency, which in Montana is the State Department of Health and Environmental
Sciences, Health Services and Medical Facilities Division. The state agency
makes grants to local programs, which provide direct services to the clients.
Responsibi 1 ities
1. Local Agencies: Local agencies, the majority of which are local healthy
departments, hire staff, issue vouchers to clients, maintain recorGS,(
provide nutrition services, operate a referral system for health care and
community services, monitor food vendors, interpret state policies and
procedures, and are responsible for outreach.
2. State Agencies: Provide funding to local agencies through contracts,
maintain the food delivery system and fiscal responsibility, interpret USDA
regulations, develop policies and procedures for program operation and
monitoring, give technical assistance and training for local agencies in
nutrition and administration, and write the State Plan.
3. USDA Regional Office: Performs management evaluation on the state and
local levels to ensure compliance with federal regulations, FNS guidelines
and the State Plan; provide technical assistance and act as a clearinghouse
for USDA policies and information; and distribute funds to the state
agencies in accordance with published funding formulas. Montana is part of
the USDA's Region VII, based in Denver, Colorado.
History of WIC in Montana
WIC began in 1974, with two pilot projects on the Fort Peck and Northern
Cheyenne Reservations. By the end of 1974 approximately 800 women, infants and
children were receiving program benefits monthly. Total program funds at that
time were approximately $120,000. In the beginning of 1976, the caseload had
reached 7,900 monthly in 10 counties and 7 reservations. December, 1978 saw
over 10,200 participants served by WIC. By January of 1980, the caseload had
risen to 12,200 monthly, and in addition to the 7 Indian Reservations, the -
participants of 39 counties were being served by the WIC Program. The annual '
X-l
food and administrative funds allocated to Montana amounted to over $4 million.
In January of 1981 the caseload was 14,466 participants receiving program
benefits. The food and administrative funds allocated to Montana were approxi-
mately $5 million dollars. By January, 1983, the caseload had dropped to 12,675
participants as a result of funding cutbacks. The annual funding allocation to
Montana had decreased to $4.4 million.
An increase in funding to about- $6.3 million in FFY 1986 allowed the caseload to
rise to 13,083 in February, 1986.
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V
REGULATIONS
(Optional -- Place your copy of the regulations
here or keep them in a separate notebook, handy
for easy reference. )
X-9
AGREEMENT
An Agreement is hereby made between ^__ (County) and the
Montana Department of Health and Environmental Sciences (DHES). The parties, in
consideration of mutual covenants and stipulations described below, agree as
follows:
SECTION I PURPOSE
The purpose of this Agreement is to provide the services of the USDA's Special
Supplemental Food Program for Women, Infants and Children (WIC) to residents of
County.
SECTION II: SERVICES
A. The County shall, to the extent that the funding stated in Section IV
allows, do the following during the period from July 1, 198 through June 30,
198 : —
(1) Conduct the Special Supplemental Food Program for Women, Infants and
Children (WIC) by assuming all administrative, financial and professional health
service responsibilities for the WIC Program within County.
The County shall administer the WIC Program in accordance with the
current regulations contained in 7 CFR Part 246; the 1985 WIC State Plan; U.S.
Food and Nutrition Service (FNS) guidelines and instructions; and the WIC
Policies and Procedures Manual, as revised August, 1981, and updated thereafter.
(2) Provide performance, activity, and fiscal reports required by DHES,
including, but not limited to, the following:
(a) time distribution records for employees. Such records need not
be submitted to DHES in Helena, but shall be kept available at the main
office of the County for audit purposes, to be checked during regular
monitoring visits conducted by staff of DHES or independent auditors.
(b) itemized expenditure reports. The County shall submit these
reports to DHES by the 15th of each month, beginning with August, 1984,
unless DHES agrees there is a good cause for the delay (e.g., a differ-
ence between the monthly close-out dates of the WIC Program and the
County). Any adjustment to an expenditure report will be eligible for
reimbursement only if it is received by DHES prior to the end of the
calendar month following the month for which the adjusted expenditure
report is claimed.
(3) Maintain complete, accurate, documented, and current accounting of
all program funds received and expended.
(4) Ensure that no claim is submitted for reimbursement of services
already funded by other state or federal programs, or for costs which are not
allowable under 7 CFR 246.14.
(5) Obtain written prior approval from DHES before, and as a condition
of, purchasing equipment costing more than $200.00 with WIC funds. If such
approval is given by DHES and the equipment is purchased, it is the property of
DHES.
(6) Assume responsibility for the safe storage of negotiable food
vouchers and reimburse DHES for any WIC Program funds misused or otherwise
X-10
diverted due to negligence, fraud, theft, embezzlement, or other loss caused by
the County, its employees, or agents.
(7) Contract with food vendors and follow procedures for issuance of
food vouchers to WIC participants in conformity with 7 CFR Sections 246.12 and
Section VIII of the Policies and Procedures Manual cited in paragraph 1 above.
(8) Employ for the WIC program one of the following types of individuals
to perform duties of certification, prescription of WIC foods, counseling of
high risk clients, nutrition education, and planning of nutrition services to be
delivered under the program, in conformity with 7 CFR Section 246.7, 246.10, and
246.11, FNS guidelines and instructions, and the 1986 WIC State Plan: a
physician, nutritionist (with a bachelor's or master's degree in nuitritional
sciences, community or clinical nutrition, dietetics, public health nutrition,
or home economics with emphasis in nutrition), dietitian, registered nurse,
physician's assistant certified by the National Committee on Certification of
Physician's Assistants or the Montana Board of Medical Examiners, or a state or
local medically trained health official.
(9) Abide by the nutritional health plan developed by the County for FY
1986 in accordance with 7 CFR Section 246.11 (d)(2) and the 1986 WIC State Plan
and submitted to DHES.
(10) Ensure that one-sixth (l/6th) of the reimbursement claimed by the
County each month is for time spent by personnel in nutrition education of WIC
clients in compliance with 7 CFR Section 246.11 and the 1986 WIC State Plan.
(11) Assure that one staff person involved in the WIC Program attends
regularly scheduled workshops sponsored by DHES on administrative policies,
procedures, and nutrition. Other personnel deemed appropriate by the County may
attend subject to availability of funding from DHES. In the event that inclem-
ent weather intervenes, attendance at such workshops will not be mandatory.
(12) Make available to all WIC participants ongoing health services as
outlined in 7 CFR Sections 246.2 and 246.6 (b)(3) and Section V of the Policies
and Procedures Manual cited in paragraph 1 above, and inform applicants of the
health services which are available.
(13) By July 15, 198 , submit to DHES for approval a draft contract with
each satellite county listed in paragraph (1) above (if any) defining the
respective responsibilities for the WIC Program of the satellite and the County,
and provide DHES with a copy of each such contract, after execution of it,
within two months after receipt of written approval from DHES.
(14) Comply with all requirements imposed by the U.S. Department of
Agriculture concerning administrative requirements approved in accordance with
Office of Management and Budget Circular No. A-102 and A-87, including those
relating to procurement of supplies, equipment and other services, as well as
the utilization and disposition of property purchased in whole or in part with
WIC funds.
(15) Keep on file and available for review, audit and evaluation:
(a) a copy of this Agreement;
(b) information on the character of the service area and financial
eligibility standards used;
(c) complete and accurate written records of nutritional assessment
criteria, criteria for certification of applicants, foods prescribed,
nutrition care, counseling, education and referrals provided under the
WIC Program;
(dj complete, accurate, documented and current accounting of all
funds received pursuant to this Agreement and expended.
X-ll
B. DHES shall:
(1) Provide a minimum of one regularly scheduled workshop annually for
project personnel for training in administrative policies, procedures, and
nutrition services as referenced in Part A above.
(2) Pay travel expenses for the staff person attending the workshops
required by part A, paragraph (11), above. Such travel expenses shall be
reimbursed at the rates set for in-state travel of state employees in Title 2,
Chapter 18, Part 5, Montana Code Annotated, or at a rate agreed upon by the
County and DHES.
(3) Send staff to visit and monitor the County's WIC Program in order to
determine compliance with administrative and nutrition service requirements of
this Agreement.
SECTION III: EFFECTIVE DATE AND DATE TO COMPLETE SERVICES
This Agreement shall take effect as of July 1, 198 , and the services provided
pursuant to Section IA must be continued through June 30, 198 , unless this
Agreement is terminated earlier pursuant to Sections V or X.
SECTION IV: CONSIDERATION
In consideration of services rendered pursuant to this Agreement, DHES agrees to
reimburse the County for the following:
(1) salaries and fringe benefits for personnel while engaged in perfor-
mance of this Agreement, at the rate of l/12th (8.3%) per month of the funds
allocated for personnel services in the Attachment A budget; DHES will reimburse
for expenditures in excess of this amount only if it has approved the excess
expenditure before it was accrued.
(2) indirect costs (at the rate of 57c), and any other expenses necessary
and related to administration of the WIC Program by the County, considered
allowable by 7 CFR 246.12, and listed in the budget in Attachment A; expendi-
tures in any budget category (except salaries and benefits) may not exceed 10%
of that category unless DHES gives its approval in advance.
As soon as possible after execution of this Agreement, DHES shall pay the County
an advance of S .
Subject to the receipt of funds from U.S.D.A., DHES shall reimburse the County
for services performed under this Agreement upon DHES' receipt from the County
of completed and signed expenditure reports, within the time limit set in
paragraph A (2)(b) of Section II, and a signed vendor invoice request for funds.
Reimbursable expenditures for the period from July 1, 198 , through September
30, 198 , must not exceed $ .
A final statement of all outstanding reimbursable expenses must be submitted by
July 31, 198 , if they are to qualify for payment. If the total amount paid
under this Agreement exceeds all reimbursable expenses once the services under
this Agreement have been completed, the balance will be returned to DHES. Total
payments by DHES for all purposes under this Agreement shall not exceed
$
X-12
SECTION V: TERMINATION
(1) The County understands and agrees that DHES, as a state agency, is
dependent upon federal and state appropriations for its funding, and that
actions by Congress, U.S.D.A., or the Montana Legislature may preclude funding
this Agreement through the completion date stated in Section III. Should such a
contingency occur, the parties agree that DHES may set a new completion date or
terminate the contract immediately, depending upon the funding remaining avail-
able for the Agreement, and that the County will be compensated for services
rendered and expenses incurred to 5:00 p.m. of the revised completion date.
(2) In addition to the provisions of paragraph 1 above, and Section X,
either party may terminate this Agreement for failure of the other party to
perform any of the services, duties, or conditions contained in this Agreement
after giving 30 days written notice to the other party.
(3) Any termination of this Agreement is subject to the exception that
paragraph (4) of Section X, relating to retention of and access to records, will
remain in effect.
SECTION VI: ASSIGNMENT AND SUBCONTRACTING
The parties agree there will be no assignment or transfer of this Agreement, or
of any interest in this Agreement, unless both parties agree in writing. The
parties agree that no services required under this Agreement may be performed
under subcontract unless both parties agree in writing.
SECTION VII: EQUAL OPPORTUNITY
The County agrees that it will comply with Title VI of the Civil Rights Act of
1964 (P.L. 88-352) and all requirements imposed by the requlations of the
Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts
42 and 50) and Food and Nutrition Service directives or regulations issued
pursuant to that Act and its regulations, to the effect that no person in the
United States shall, on the ground of race, color, national origin, age, sex, or
handicap, be excluded from participation in, be denied the benefits of, or be
otherwise subject to discrimination under any program or activity for which the
County received federal financial assistance from the Department; and hereby
gives assurance that it will immediately take any measures necessary to effect-
uate this Agreement.
This assurance is given in consideration of an for the purpose of obtaining any
and all federal financial assistance, grants and loans of federal funds, reim-
bursable expenditures, grant or donation or federal property and interest in
property, the detail of federal personnel, the property or interest in such
property of the furnishing of services without consideration or at a nominal
consideration, or at a consideration which is reduced for the purpose of assist-
ing the recipient, or in recognition of the public interest to be served by such
sale, lease, or furnishing of services to the recipient, or any improvements
made with federal financial assistance extended to the County by DHES. This
includes any federal agreement, arrangement, or other contract which has as one
of its purposes the provision of assistance such as food, and cash assistance
for purchase or rental of food service equipment or any other financial assis-
tance extended in reliance on the representations and agreements made in this
contract.
X-13
By accepting this assurance, the County agrees to compile data, maintain records
and submit reports as required, to permit effective enforcement of Title VI and
to permit authorized U.S.D.A. personnel during normal working hours to review
such records, books and accounts as needed to ascertain compliance with Title
VI. If there are any violations of this assurance, the Department of Agricul-
ture, Food and Nutrition Service, shall have the right to seek judicial enforce-
ment of this assurance. This assurance is binding on the County, its succes-
sors, transferees, and assignees as long as it receives assistance or retains
possession of any assistance from DHES. The person or persons whose signatures
appear below are authorized to sign this assurance on behalf of the program
appl icant.
In addition, pursuant to Sections 49-2-303 and 49-3-207 of the Montana Code
Annotated, no part of this contract shall be performed in a manner which dis-
criminates against any person on the basis of race, color, religion, creed,
political ideas, sex, age, marital status, physical or mental handicap, or
national origin by the persons performing the contract. Any hiring shall be on
the basis of merit and qualifications directly related to the requirements of
the particular position being filled.
SECTION VIII: VENUE
The parties agree that, in the event of litigation concerning this Agreement,
the venue shall be in the First Judicial District of the State of Montana, in
and for the County of Lewis and Clark.
SECTION IX: MODIFICATIONS AND PREVIOUS AGREEMENTS
This instrument contains the entire Agreement between the parties, and no
previous statements, promises, or inducements made by either party or agent of
either party which are not contained in this written Agreement shall be valid or
binding. This agreement may not be enlarged, modified, or altered except in
writing, signed by the parties. No change, addition, or erasure of any printed
portion of this Agreement shall be valid or binding upon either party.
SECTION X: AUDITING, RECORD RETENTION, AND ACCESS TO RECORDS
(1) The County agrees to allow access to the records of the activities
covered by this Agreement as may be necessary for legislative audit and analysis
purposes in determining compliance with the terms of this Agreement, as required
by Section 5-13-304, Montana Code Annotated. Notwithstanding the provisions of
Section V, this Agreement may be terminated upon any refusal of the County to
allow access to records necessary to carry out the audit and analysis referred
to above.
(2) The County must provide DHES by September 30, 1986, with a copy of
an agency audit covering the time period stated in Section III and complying
with the audit requirements of the federal Office of Management and Budget's
(0MB) Circular A-102, Attachment P.
(3) The State of Montana, DHES, the U.S. Department of Agriculture, Food
and Nutrition Service, the Comptroller General of the United State, and the
General Accounting Office of the United States, or any of their duly authorized
representative, have the right of access to any books, documents, papers, and
records of the County which are pertinent to the services provided under this
contract, for purposes of making an audit, excerpts, or transcripts. Further,
for purposes of verifying cost or pricing data submitted in conjunction with the
negotiation of this contract or any amendments thereto, the State and DHES,
X-14
until the completion date cited in Section III, have the right to examine those
books, records, documents, papers, and other supporting data which involve
transactions related to this Agreement or which will permit adequate evaluation
of the cost or pricing data submitted, along with the computations and projec-
tions used for them.
(4) Financial records, supporting documents, statistical records, and
all other records documenting the services provided by the County under this
Agreement must be retained for a period of 3 years after the date of submission
of the final statement of reimbursable expenses referred to in Section IV. The
County agrees to make the records described herein available at all reasonable
times at its general offices. If any litigation, claim, or audit is started
before the expiration of the 3-year period, the records must be retained until
all litigation, claims, or audit findings involving the records have been
resolved. The County, whenever it is ready to dispose of the above records,
will submit them to the Food and Nutrition Service if that agency has requested
them.
SECTION XI: SEVERABILITY
It is understood and agreed by the parties hereto that if any term or provision
of this contract is by the courts held to be illegal or in conflict with any
Montana law, the validity of the remaining terms and provisions shall not be
affected, and the rights and obligations of the parties shall be construed and
enforced as if the contract did not contain the particular term or provision
held to be invalid.
SECTION XII: LIAISONS
The County's liaison to DHES for purposes of this Agreement is the following
person, or that person's successor.
Name Title
DHES' liaison to the County for purposes of this Agreement is David Thomas, or
his successor.
SECTION XIII: EXECUTION
This Agreement consists of 8 pages and one attachment. The original is to be
retained by the Financial Management Division of DHES. A copy of the original
has the same force and effect for all purposes as the original.
X-15
To express the parties' intent to be bound by the terms of this Agreement, they
have executed this document on the dates set out below:
Date
COUNTY
By:
Signature
Approved for legal content by:
Print Name and Title
Address
, MT
Employer's ID No.
DEPARTMENT OF HEALTH AND
ENVIRONMENTAL SCIENCES
Date
BY:
Robert L. Solomon
Contracts Officer
Eleanor A. Parker
Date
X-16
ATTACHMENT A
AGENCY:
FTE's Competent Professional Authority
Nutrition Aide
Sal
TOTAL
aries
Benefits
Indirect
Travel
Equipment
Supplies
Rent
Telephone
Postage
Utilities
Repairs
Contracted
Nutrition Education
Other
OPERATING EXPENSES
Services
TOTAL
July 1, 1985 - September 30, 1985
October 1, 1985 - June 30, 1986
X-17
Outline for a Satellite Agreement
This outline is to be used as a guide in preparing satellite agreements.*
Section I: Each party's specific services must be defined in Section I.
The administrative and supervisory responsibilities must be
clearly delineated between the satellite and parent agency.
We are particularly concerned as to which party is responsi-
ble for providing the required health services to WIC
clients in the satellite communities.
Section II: The effective dates of duration must coincide with your
state agreement, which normally spans fiscal year July 1
through June 30.
Section III: A satellite budget must be a part of the satellite agree-
ment.
Sections IV to XI: These sections are self-explanatory.
Consult your agency's legal representative before completing this agreement.
Your legal counsel should provide assistance in reviewing all local agency
contracts.
NOTE: The information in this agreement would also be used when a health
agency must contract with another provider to conduct certain required
WIC services.
Example: When a hospital is the parent WIC agency it must contract
with a public agency, private non-profit agency or private
provi-der to provide Well Child Conferences for participating
infants and children.
*
A Satellite is defined as a WIC program that is operated by another WIC pro-
gram. The parent agency has primary administrative responsibility for the
satellite program and contracts directly with the State Agency. A satellite
program is located outside the defined project area.
X-18
MODEL SATELLITE AGREEMENT: WIC PROGRAM:
A cooperative agreement is hereby made between ' (hereinafter
referred to as "Satellite") and the (hereinafter
referred to as "Local Agency"), in order to extend to County
the services of the. Women, .Infants and Children (WIC) ^Program, for which Local
Provider is responsible under separate contract with the Montana Department of
Health and Environmental Sciences (DHES). The parties, in consideration of
mutal covenants and stipulations described below, agree as follows:
SECTION I: SERVICES
A. The Local Agency agrees to perform the following services:
(1)
(2)
(3)
etc.
B. The Satellite agrees to perform the following services:
(1) Maintain a complete, accurate, documented, and current accounting of
WIC Program funds received from Local Agency.
(2)
(3)
etc.
(NOTE: Each party's respective duties for the WIC Program should be carefully
described above. Examples of duties are listed below; these and any other
duties should be listed under either A or B above, depending upon which agency
assumes the responsibility:)
(1) Maintain whatever WIC performance, activity and fiscal reports are
required by DHES, including, but not limited to the following:
(a) Time distribution records for employees;
(b) Itemized monthly expenditure reports. (If the Satellite keeps
these reports, the agreement must include a requirement that
the Satellite submit a copy to the Local Provider by the 10th
day of each month following the month to which the report
relates.)
(2) Maintain careful records for each WIC client.
(3) Issue food vouchers to WIC participants in conformity with 7 CFR,
Sections 246.10 and 246.11.
X-19
(4) Employ or contract for a registered dietitian or other person whose
qualifications are approved by the Montana Department of Health and
Environmental Sciences (DHES) to perform duties of certification,
prescription of MIC foods, counseling of high risk clients, and
planning nutrition services to be delivered under the program, in
conformity with 7 CFR Sections 246.6 through 246.9 and the 1984 WIC
State Plan of DHES.
(5) Employ or contract for program assistants as necessary to carry out
clerical duties such as making client appointments, issuing drafts,
and preparing reports.
(6) Provide space for program operations, specifically interviews,
storage for materials and supplies, and utilization of educational
aids (projectors, tape players, etc.).
(7) Make available to all WIC participants ongoinq health services as
outlined in 7 CFR Sections 246.2 and 246.6(b)(3) and Section 1 1 -A of
DHES' most current WIC Policies and Procedures Manual, and as
specified by DHES' Nursing Bureau.
SECTION II: EFFECTIVE DATE AND DATE TO COMPLETE SERVICES
This Agreement shall take effect as of , and the services required
by Section I shall continue through (date), unless this
Agreement is terminated earlier pursuant to Sections IV.
SECTION III: CONSIDERATION
Total
exceed
A final statement of all reimbursable expenses must be submitted within 30 days
after the latest date cited in Section II if they are to qualify for payment.
SECTION IV: TERMINATION
(1) Satellite understands and agrees that since funding for this Agreement is
\i) saienue understands and agrees tnax since Tunoing Tor tnis agreement is
available through a contract by Local Provider with DHES, a state agency which
is dependent upon federal and state appropriations for its funding, actions by
Congress or the Montana Legislature may preclude funding this Agreement com-
pletely through the completion date stated in Section II. Should such a contin-
gency occur, the parties agree that the Local Agency may set a new completion
date or terminate the contract immediately, depending upon the funding remaining
available for the Agreement, and that the Satellite will be compensated for
services rendered and expenses incurred to 5:00 p.m. of the revised termination
date.
(2) In addition to the provisions of paragraph (1) above and Section IX,
either party may terminate this Agreement for failure of the other party to
X-20
/
perform any of the services, duties, or conditions contained in this Agreement
after giving 30 days written notice to the other party.
(3) Any termination of this Agreement is subject to the exception that
paragraph (2) of Section VII, relating to retention of and access to records,
will remain in effect.
SECTION V: EQUAL OPPORTUNITY
The Satellite agrees that it will comply with Title VI of the Civil Rights Act
of 1964 (P.L. 88-352) and all requirements imposed by the regulations of the
Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts
42 and 50) and Food and Nutrition Services directives or regulations issued
pursuant to that Act and its regulations, to the effect that no person in the
United States shall, on the ground of race, color, national origin, age, sex or
handicap, be excluded from participation in, be denied the benefits of, or be
otherwise subject to discrimination under any program or activity for which the
Satellite receives federal financial assistance from the Local Agency, and
hereby gives assurance that it will immediately take any measures necessary to
effectuate this agreement.
This assurance is given in consideration of and for the purpose of obtaining any
and all federal financial assistance, grants, and loans of federal funds,
reimbursable expenditures, grant or condition of federal property and interest
in property, the detail of federal personnel, the sale and lease of, and permis-
sion to use, federal property or interest in such property or the furnishing of
services without consideration or at a nominal consideration, or at a consid-
eration which is reduced for the purpose of assisting the recipient, or in
recognition of the public interest to be served by such sale, lease, or furnish-
ing of services to the recipient, or any improvements made with federal finan-
cial assistance extended to the Satellite by the Local Agency. This includes
any federal agreement, arrangement, or other contract which has as one of its
purposes the provision of assistance such as food, and cash assistance extended
in reliance on the representations and agreement made in this assurance.
By accepting this assurance, the Satellite agrees to compile data, maintain
■~rmit effective enforcement of Title
lei during normal working hours to
By accepting wis assurance, tne bateinte .^
records and submit reports as required, to permit effective enforcement of Title
VI and to permit authorized U.S.D.A. personne
enforcement of this assurance. This assurance is binding on the County, its
successors, transferees, and assignees as long as it receives assistance or
retains possession of any assistance from the Local Agency. The person or
persons whose signatures appear below are authorized to sign this assurance on
behalf of the Satellite.
In addition, pursuant to Sections 49-2-303 and 49-3-207 of the Montana Code
Annotated, no part of this contract shall be performed in a manner which dis-
criminates against any person on the basis of race, color, religion, creed,
political ideas, sex, age, marital status, physical or mental handicap, or
national origin by the persons performing the contract. Any hiring shall be on
the basis of merit and qualifications directly related to the requirements of
the particular position being filled.
X-21
SECTION VI: MODIFICATIONS AND PREVIOUS AGREEMENTS
This instrument contains the entire Agreement between the parties, and no
previous statements, promises, or inducements made by either party or agent of
either party which are not contained in this written Agreement shall be valid or
binding. This agreement may not be enlarged, modified, or altered except in
writing, signed by the parties. No change, addition, or erasure of any printed
portion of this Agreement shall be valid or binding upon either party.
SECTION VII: AUDITING, RECORD RETENTION, AND ACCESS TO RECORDS
(1) The Satellite agrees to allow access to the records of the activities
covered by this Agreement to Local Agency, DHES, or as may be necessary for
legislative audit and analysis purposes in determining compliance with the terms
of this Agreement. In addition to the provisions of Section IV, this Agreement
may be terminated upon any refusal of the Satellite to allow the access to
records described above.
(2) Financial records, supporting documents, statistical records, and all
other records supporting the services provided by the Satellite under this
Agreement must be retained for a period of 3 years after the date of submission
of the final statement of reimbursable expenses referred to in Section III. The
Satellite agrees to make the records described herein available at all reason-
able times at its general offices. If any litigation, claim, or audit is
started before the expiration of the 3-year period, the records must be retained
until all litigation, claims, or audit findings involving the records have been
resolved.
SECTION VIII: SEVERABILITY
It is understood and agreed by the parties hereto that if any term or provision
of this contract is by the courts held to be illegal or in conflict with any.
Montana law, the validity of the remaining terms and provisions shall not be
affected, and the rights and obligations of the parties shall be construed and
enforced as if the contract did not contain the particular term or provision
held to be invalid.
SECTION IX: LIAISONS
The Satellite's liaison for purposes of this Agreement is the following person,
or that person's successor.
Name Title
The Local Agency's liaison for purposes of this Agreement is the following
person, or that person's successor.
Name Title
DHES' liaison to both parties for purposes of this Agreement is the following
person or that person's successor:
Name Title
X-22
0
The parties agree that these persons will be the first contacts concerning any
problems or questions that may arise in the implementation of the terms of this
Agreement.
SECTION XIII: EXECUTION
This Agreement consists of pages and one appendix. The original will be
retained by the Local Agency. A copy of the original has the same force and
effect for all purposes as the original. A copy of the original Agreement will
be sent by the Local Agency to DHES on the day following the Agreement's exe-
cution.
To express the parties' intent to be bound by the terms of this Agreement, they
have executed this document on the dates set out below:
Date Satellite's agent's signature
Print name and title of above
Address of Satell ite
Federal Employer's ID No.
Date Signature of agent of Local Agency
Print name and title of above
Address of Local Agency
Federal Employer's ID No,
*
X-23
APPLICATION/CERTIFICATION SECTION
I. Definitions
II. Application/Certification Process
End of Certification
III. Transferring Participants and Migrants
IV. Waiting List - Process
V. Ineligibility
VI. Instructions for Certification Record Form
VII. Verification of Certification Cards
VIII. Participant's Rights and Obligations
WIC Participant's Responsibility Form
IX. Appointments/Scheduling"
X. Determination of Eligibility-Criteria
A. Population
B. Residential
C. Financial
D. Nutritional
XI. Caseload Management
A. Priority System
B. Waiting List Guidance
XII. Chart Information - Contents
XII. Health Services to be Provided
X-24
DEFINITIONS
1. Breastfeeaing Woman: Woman up to 1 year postpartum who is breastfeeding an
infant.
2. Caseload: The number of persons certified eligible and participating in
the WIC Program at any point in time. Persons certified eligible and wait
listed are not considered to be participating in the WIC Program, and
therefore are not included when assigning caseload limits or tallying
caseload being carried at a point in time.
3. CI ient: Any WIC Program participant.
4. Encumbrance: A designated amount of money set aside for a specific pur-
pose.
5. Fair Hearing: Procedure through which an indiviaual may appeal a State or
local decision which results in denial of Program participation, or suspen-
sion or termination from the Program.
6. Farni ly: Group of related or unrelated individuals, not residents of an
institution, living together as one economic unit.
7. Food Package: Supplemental foods given to participants monthly.
8. Food Vendor: Local grocer, dairy or other merchant who, through a signed
agreement with the local agency, provides WIC foods in exchange for the WIC
voucher.
9. Infant: Person 0-12 months of age.
10. Initial Visit: The first time a person visits a WIC clinic to request
program benefits, whether an inquiring person in person or a visit for an
appointment established by telephone.
11. Local Project/Program/Agency. Organizational body that provides WIC
benefits within a defined project area.
12. Migrant Farmworker: A person or member of a family whose prime employment
is agriculture on a seasonal basis who has been so employed within the last
24 months and who has established for the purpose of such employment a
temporary residence.
13. Object Class Budget Items: Line items such as salaries, fringe benefits,
postage, etc.
14. Participant: Pregnant, breastfeeding, post partum women, infants and
children who are receiving vouchers under the program.
15. Priority System: Applied to persons on waiting list to ensure those at
highest nutritional risk are the first ones chosen to fill vacancies.
X-25
16. Reallocation: Process by which USDA monies are moved from one state agency
which is spending at a lower rate and given to another state agency that is
able to spend the money more rapidly due to larger caseloads.
17. Retail Purchase System: A system in which the participant obtains WIC
foods through an authorized food vendor, i.e., grocer or dairy.
18. Satel lite: A WIC Program operated by another WIC Program which has primary
administrative responsibility for the program and contracts directly with
the State Agency. A satellite differs from a site in that it is located
outside the defined project area, i.e., county or reservation.
19. S i te : Within a defined project area there may be mere than one site/clinic
that offers services to WIC participants.
20. Staffing Pattern: Ratio of WIC staff needed to number of participants
served.
21. State Agency: USDA ' s administrative designee for WIC in the state.
22. State Plan: Requirement of the State Agency by USDA which indicates action
plans necessary to meet USDA regulations.
23. VOC Card: Verification of Certification Card issued to clients who are
transferring to another WIC service area, to show proof of eligibility.
24. Voucher: Check-like document which is traded by the WIC participant for
food at his/her local vendor.
25. Waiting List: List of applicants waiting to be accepted in the wIC Program
when vacancies occur.
X-26
II. APPLICATION/CERTIFICATION PROCESS
Person 1. Calls or visits WIC clinic and requests an appointment.
(See V-3, definition of Initial Visit.)
WIC Staff 1. Requests name, address and date of birth.
Person 1. Is residential ly and categorically eligible.
WIC Staff 1. Schedules an appointment for person. Provides instructions
to the person as to whom must be present at the appointment
and what proof of residential and financial status must be
supplied.
Applicant 1. Arrives for appointment.
WIC Staff 1. Gives applicant Financial Statement to fill' in.
2. Interviews applicant to determine if currently eligible.
Fills in name, residential, financial and physical data
sections of WIC Certification Record Form.
3. May conduct prenatal, child health and dietary interviews.
4. Gives applicant's file to Competent Professional Authority.
NOTE: Applicant may be determined to be ineligible at
residential, financial, and nutritional points in
the process. If the applicant is ineligible, go to
page V-10, "Ineligibility."
1. Evaluates nutritional information of applicant.
2. Codes nutritional problems on Certification Record.
3. Assigns nutritional priority category, and ranking within
priority category if necessary.
4. If the applicant has met the residential, financial and
nutrition criteria, the applicant is eligible. If space is
available, services are provided.
If space is not available, go to page V-8, "Waiting
List."
5. Signs and dates the Certification Record.
WIC Staff 1. Notifies applicant of eligibility, responsibilities and
participant's rights (see page V-32).
2. Gives applicant "Participant's Responsibilities" form to
sign.
Competent
Professional
Authority
X-27
Applicant 1. Signs "Participant's Responsibilities" and returns to WIC
staff.
WIC Staff 1. Retains signed copy of "Participant's Responsibilities" for
file and gives one copy to applicant, now a participant.
2. Issues vouchers.
3. Assigns date for next appointment and gives appointment card
to participant.
4. If new applicant (first time to receive WIC benefits by this
agency) sets up file.
*******************************************************
End of Certification
WIC Staff 1. 15-30 days before the end of a current certification period,
advises participant that current period of eligibility will
expire on (date)
2. If participant will become ineligible on that date, advises
participant of upcoming ineligibility. (Go to "Ineligibil-
ity," page X-33. )
X-28
III. TRANSFERRING PARTICIPANTS AND MIGRANTS
Person
1
2
WIC Staff
1
Appl icant
1
2
WIC Staff
1
Competent
Professional
Authority
Calls or visits WIC clinic and requests an appointment.
Informs WIC staff is a transferring participant or a mi-
grant.
Schedules an appointment for the applicant.
Arrives for the appointment.
If available, presents current VOC Card to WIC staff.
If applicant does not have a current VOC card, contacts
applicant's previous local agency to determine if applicant
is currently certified.
If applicant is not currently certified, go to page V-4
"Application/Certification," and treat person as a new
appl icant.
If applicant is currently certified, fills in WIC Certifica-
tion Record as completely as possible.
Requests additional information
previous local agency, which may
Certification Record upon receipt.
from applicant's
used to update the
Instream migrant farmworkers and their family members with
expired VOC cards shall be declared to satisfy the State
agency's income standard; provided, however, that the income
of that instream migrant farmworker family is determined at
least once every 12 months. Any determination that members
of an instream migrant farmworker family have met the income
standard, either in the migrant's home base area before the
migrant has entered the stream for a particular agricultural
season, or in an instream area during the agricultural
season, shall satisfy the income criteria for any subsequent
certification while the migrant is instream during the
12-month period following the determination.
Determines nutritional problems and codes this information
on Certification Record
If space is available, certifies transferring partici-
pant/migrant for remainder of current certification period.
If space is not available, places transferring partici-
pant/migrant on the Waiting List ahead of all waiting
applicants regardless of priority category. (Go to
page X-31, "Waiting List.")
Signs- and dates Certification Record Form.
X-29
WIC Staff 1. Notifies transferring participant/migrant of place in
program.
2. Informs them of their responsibilities and rights.
3. Gives transferring participant/migrant "Participant's
Responsibilities" Form to sign.
Transferring 1. Signs "Participant Responsibilities" and returns to WIC
Participant/ staff.
Migrant
WIC Staff 1. Retains signed copy of "Participant's Responsibilities" for
file and gives one copy to participant.
2. Issues vouchers.
3. Assigns date for next appointment and gives appointment card
to participant.
4. Sets up file.
5. At end of certification, go to "End of Certification," page
X-28.
X-30
IV. WAITING LIST
WIC Staff 1. If there is no space available in the program, notifies
applicant that they will be placed on a waiting list.
2. Places transferring participant with current verification of
certification or a migrant on the waiting list ahead of all
waiting applicants regardless of the priority category of
their nutritional risk.
A. If current certification period of a transferring
participant expires while they are on the waiting list,
transferring participant is then moved to a place on
the waiting list according to their nutritional risk
priority.
B. Migrant applicants retain their position on the waiting
list ahead of all other waiting applicants.
3. Places other eligible applicants on waiting list according
to nutritional risk priority category.
4. Sets up applicant's file.
X-31
WIC Staff
Competent
Professional
Authority
WAITING LIST - SPACE AVAILABLE
1. If space in program becomes available, selects first:
A. Transferring participants and migrants, then
B. other eligible applicants, highest nutritional risks
first to fill space available or until waiting list is
empty.
2. Notifies selected individuals of the opening of space in the
program.
3. Establishes appointments for them.
4. Pulls files and gives them to Competent Professional
Authority. .
1. Prepares Nutrition Care Plan.
2. Writes food package prescription.
3. Certifies for appropriate time period. Signs and dates new
WIC Certification Record Form.
**************************
Applicant 1,
WIC Staff 1.
Applicant 1.
WIC Staff 1.
r>
L. .
3.
4.
Arrives for appointment.
Notifies applicant of eligibility, responsibilities and
participant's rights.
Gives applicant "Participant's Responsibilities" Form to
sign.
Signs "Participant's Responsibilities" Form and returns to
WIC staff.
Retains signed copy of "Participant's Responsibilities" for
file and gives one copy to the applicant.
Provides nutrition services according to the care plan.
Issues vouchers according to the food package prescription.
Assigns dates for next appointment and gives participant an
appointment card.
X-32
INELIGIBILITY
WIC Staff
Appl icant/
WIC Staff
Determines applicant/participant to be ineligible for one of
the following reasons:
A. Categorical ineligibility (child after 5th birthday,
etc. ) .
B. Residential ineligibility.
C. Financial status.
D. Nutritional status.
Advises applicant/participant of their ineligibility with
explanation. Written notice of ineligibility is provided at
least 15 days in advance of the date of termination of
program benefits.
Informs applicant/participant of Fair Hearing procedure and
gives them a copy of the form, "Individual Fair Hearing
Procedure." (See "Fair Hearing Procedure," page VII-2.)
Fills in and gives applicant/participant Fair Hearing Card
to sign.
Signs Fair Hearing Card and returns it to WIC staff.
Participant
Signs Fair Hearing Card and gives copy to applicant/partici-
pant.
Files all pertinent documentation and original copy of Fair
Hearing Card in file.
X-33
INSTRUCTIONS
Certification Record-I
Montana WIC Program
ALL ENTRIES ARE TO BE PRINTED. PLEASE PRINT CLEARLY
1. Visit Date.
Enter the day the applicant is in the clinic and applies for benefits. Enter
month, then day and finally the last two numbers of the year. (Example 1/5/84. )
This is the initial visit date for those applicants applying in person for the
first time.
Clinic No.
This is your clinic number, and will always be the same for each clinic site.
Enter the three numbers of your clinic number in the space provided. The clinic
number must match the number on the drafts which will be issued to the appli-
cant.
Family Number.
A unique family number is assigned to each family by clinic staff. This number
cannot be assigned to any other family. Enter the family number in the space
provided. Assign foster children their own family number. This will be the
foster child's number even if the foster family changes.
Member No.
Each member of a family will be assigned a unique number that identifies them
within the family. This number will be used with the family number. Enter the
member number in the space provided. Begin with "1" for the first member, "2"
for the second, etc.
"X" Here if Migrant.
If this applicant is a migrant, place an "X" in the box. If the applicant is
not a migrant, leave the box blank.
The applicant is a migrant if an individual or part of a family whose employment
is seasonal agricultural work and who have established a temporary residence due
to employment.
"X" Here if First Visit.
If this is the person's first visit to your clinic, or if you
person into the certification system for the first time, pli
box. Leave this box blank for any subsequent visit or update
are entering this
lie, pi ace an "X" in the
pdate to the system.
X-34
Certification.
Mark the box which indicates which certification visit this is for the appli-
cant. "X" the box labeled "1" if it is the initial visit, "2" if it is a second
or subsequent visit, and "3" if it is a transferring participant. Once you have
marked box "2" you do not need to mark a certification box again. Do not write
the number in the box.
"X" Here if Record is to be Deleted.
If the record of this person is to be deleted, place an "X" in the box. If the
record is to stay, leave the box blank.
2. Appl icant.
Last Name.
Print only the applicant's last name on this line.
First Name.
Print the applicant's first name on this line.
Kiddle Name.
Print the applicant's middle name on this line. If the applicant does not have
a middle name leave the space blank. If you only have a middle initial, write
in the middle initial .
Birthdate.
Enter the birthday of the applicant. Enter month, then day and finally the last
two numbers of the birth year.
Sex.
If the person is male, check that box. If the applicant is female, check that
box.
Ethnic Code.
The ethnic group codes are:
1. - White, not of Hispanic Origin
2. - American Indian or Alaskan Native
3. - Black, not of Hispanic Origin
4. - Asians or Pacific Islanders
5. - Hispanic
6. - Other
7. - Unknown
X-35
Select the code which comes closest to the ethnic background of the applicant.
Mark the box above the number that is the code for the ethnic group of the
applicant. An entry must be made in one, and one only, of the Ethnic Code
boxes. Place an "X" in the appropriate box. Instruct the applicant that this
information is used for program reporting purposes only and does not affect
el igibil ity.
3. Residential Eligibility
Street.
On this line, print the street address (or post office box number, etc.) of the
applicant. If the applicant does not have a street or other address, leave it
blank. If you need to use more than one line for the street address, you may
enter the information on the form but it may not appear on your printout.
City.
On this line, print the city where the applicant lives. If the applicant does
not live in a city, print the city of the mailing address. If the applicant
does not live in the city of their mailing address, be sure the county of
residence or reservation of residence is coded correctly.
State.
MT is filled in for you, to indicate "Montana."
Zip Code.
Fill in the last three numbers of the zip code of the applicant's mailing
address.
County or Reservation Code.
From the list of county and reservation codes, select the two-digit number (01
through 63) for the county or reservation in which the applicant lives. Enter
this number on the line provided. This number is not the same as the clinic
number.
NOTE: Residential information must be repeated on each family member's
form.
4. Financial Eligibility
Look at the current WIC Income Eligibility Table and the WIC Financial Statement
filled in by the applicant. Determine the WIC income code of the applicant,
using the number of family members and then the income (every two weeks, monthly
or yearly), or aid received. The WIC income code will be 1 through 7. Mark the
box above the income code of the applicant with an "X". Do not write the number
in the box.
Example: ■ ( ) ( ) ( ) ( X ) ( ) ( ) ( )
12 3 4 5 6 7
X-36
(
The applicant's income code is 4. Remember that income code 7 is ineligible as
over-income.
5. Physical Data.
In this area, information abut the physical characteristics of the applicant
will be entered. A date (month, day and year) must be entered in each space
provided if data is entered. If a date is entered, data must also be entered.
If physical data is not taken (a hematocrit on an infant for example), leave the
date blank.
Length or Stature/Height.
Enter month, day, year of the length or stature/height measurement. Enter the
measurement in either inches or in centimeters; you do not need to do both.
Enter the recumbant length, stature or height without shoes.
Inches.
If you record the measurement in inches, enter with all fractions of an inch
converted to eighths. A fraction must be used with every entry, including
women. Example: 64 1/2" would be recorded as 64 2/3". 64" would be recorded
as 64 0/8.
Centimeters.
Use whole numbers for centimeters. Example: 160 centimeters would be recorded
as 160. 98 centimeters would be recorded as 98. Do not use a fraction of a
centimeter.
Weight.
Enter month, day, year of the weight measurement. The date must be filled in
even if it is the same as the date the length or stature/height was taken. Enter
the weight measurement in either pounds or kilograms. Weigh with minimal
clothing and without shoes. For a woman, give the weight measured on the date
of her certification.
Pounds.
Enter pounds to the nearest 1/4 pound. Convert ounces to the nearest quarter
pound. A fraction must be used with every entry, including women. Example: If
weight is 116 3/4 pounds, the entry would be 116 3/4. 125 pounds would be 125
0/4.
Kilograms .
If weight is entered in kilograms, weight is entered to the tenth of a kilogram.
Example. 22.5 kilograms would be entered 22 5/10. 33 Kilograms would 33 0/10.
Hematocrit or Hemoglobin.
Either or both items of information may be provided. For infants under 6 months ,
old, neither item is required, but may be entered if available.
X-37
Hematocrit.
Enter the month, day and year on which the hematocrit or hemoglobin test was
made. Date must be filled in. Enter the result of the hematocrit determination
to the nearest percent {%) on the line provided. Example: If the hematocrit is
45%, enter 45. If it is 45.2, enter 45.
Hemoglobin.
Enter the result of a hemoglobin determination in gm/100 ml on the line provid-
ed. Record to the nearest 10th of a gram per 100 milliliters. Do not leave the
tenths position blank if it is 0; enter a zero in this case. Example: Hemoglo-
bin is 12.5 gm/100 ml, record as 12 5/10. Hemoglobin is 12 gm/100 ml., record
as 12.0.
FOR CHILD:
Birth Weight.
Birth weight may be entered in pounds and ounces OR IN GRAMS. This information
should be entered if available. If the parent or guardian cannot supply this
information, leave it blank.
Pounds.
Enter pounds to the nearest ounce. Round ounces to the nearest whole number. Do
not use a fraction of an ounce.
Grams.
Use whole numbers and record to the nearest gram. Example: Infant weighed 900
grams at birth. Record as 900. Infant weighed 2,370 grams at birth. Record as
2370.
Is Child Being Breast Fed Now?
If the child is being breast fed at the time of visit, mark the box labeled
"YES." You do not need to enter any more information in this section at this
time. If the child is not being breast fed, mark the box labeled "NO." Go on
to the next question. When a child is no longer breastfed this information
should be updated at the next certification.
Was the Child Ever Breast Fed?
If the child has never been breast fed, mark the box labeled "NO." If the child
has at one time been breast fed, mark the box labeled "YES" and go on to the
next question.
If "YES," How Many Weeks?
Determine the number of weeks that the child was breast fed from information
given by the parent or guardian, and enter here. Convert months to weeks. The
highest number of weeks that can go on the record is "98." Use "99" if the
number of weeks breastfed is unknown.
X-38
hOR WOMAN:-
Determine the category of a woman applicant. Mark the appropriate box, box #1
for a pregnant woman, and box #2 for a breastfeeding woman. The Montana WIC
Program at this time does not serve post-partum women (box #3). One of these
boxes must be marked if it is a "first visit" for a woman.
Pregnant Breastfeeding PP
Example: For Woman: (X) ( ) ( )
1 2 3
This applicant is pregnant.
6. Nutritional Eligibility
Information about the applicant's nutritional problems will be entered in this
section. The Nutritional Problems Table is your reference for the codes avail-
able to use. After determining the nutritional problem(s) of the applicant
select the correct four-digit code(s) from the table for the problem(s) iden-
tified. Enter the number(s) of the problem(s) in the spaces provided. There
are up to nine spaces available for the codes of the nutritional problems.
Leave blank those spaces that are not needed.
Priority.
Determine the nutritional risk priority of the applicant. Mark the box, 1-6,
for the nutritional risk priority of the applicant.
Example: ( ) ( X ) ( ) ( ) ( ) ( )
12 3 4 5 6
The applicant is Priority 2. Enter only one priority, the highest one that
applies to the applicant.
If you have identified a nutritional problem for which you find no code, you
must call a registered dietitian at 444-4740, or write a note to the dietitian
and attach it to the white copy of the certification form. A dietitian will
reply to your need. Do not fail to code a nutritional problem for a client. You
must contact the dietitian for any nutritional problems which have been over-
looked in the Nutritional Problems Table.
7. Certification
If the applicant is certified and will be receiving benefits: Mark the box
labeled "CERTIFIED ELIGIBLE ( )" with an "X" and fill in the date that the
certification begins; month, day, year, and the date that certification ends;
month, day, year. For a pregnant woman, the end date for the purpose of this
form is six weeks after her due date. In this case the end date is only your
best estimate, and the applicant may be served until her actual 6 weeks post-
partum date.
If the applicant is not eligible for certification:
Mark the box labeled "CERTIFIED INELIGIBLE ( ) WRITTEN STATEMENT OF REASON
..." with an "X".
X-39
8. Waiting List
If the applicant is eligible, but must be placed on the waiting list: Mark
first the box labeled "CERTIFIED ELIGIBLE." DO NOT enter a begin date or end
date.
Mark the box "X" HERE ( ) IF PLACING ON A WAITING LIST. In order to place an
applicant on the waiting list, you must fill in all the eligibility information,
including residential, financial and nutritional, as well as the clinic number,
family number, etc.
If the applicant is on the waiting list and is to be removed: Mark the box "X"
HERE ( ) IF REMOVING FROM WAITING LIST. This box must be marked when the
applicant is certified, or is removed from the Waiting List for any other
reason. Then complete the certification information, indicating whether the
applicant is eligible, with begin and end date, or ineligible.
9. Signature
The certifying authority must sign and date the certification form in the space
provided. The certification document is not valid and may be returned to the
local agency for proper signature unless signed and dated by a competent profes-
sional authority.
Error Correction
If you need to correct a certification record that has already been submitted,
you will first fill in the grey area on the form which includes the date, the
clinic number, family number, and member number. This will identify the record
that is to be corrected. Then fill in only those boxes needing correction. For
example, if the date of a hematocrit is correct, but the hematocrit is not, you
need only enter the hematocrit information. You do not need to redate it.
DO NOT update measurements or addresses taken between certifications. This
information is for your use only.
If you need to correct the clinic, family or member number, you must first fill
in one form with the incorrect information and mark the box "X" HERE ( ) IF
RECORD IS TO BE DELETED. Then you must completely fill in a new form with all
the certification information as well as the new clinic, family and member
number. Remember that deleting the information will completely eliminate any
data that has been stored under that number.
X-40
STATE OF MONTANA
DEPARTMENT OF HEALTH 1
ENVIRONMENTAL SCIENCES
HELENA. MT 59620
vVIC CERTIFICATION RECORD— i
SPECIAL SUPPLEMENTAL FOOD PROGRAM
FOR WOMEN INFANTS. AND CHILDREN
PLEASE PRINT
VISIT D ATE _
APPLICANT
CLINIC NO.
LAST NAME
FtRST NAME
MIODLENAME
MEMBER NO.
-X" HERE IF MIGRANT LJ
-X- HERE IF FIRST VISIT LJ
CERTIFICATION
Initial Subsequent (2 +)
D □
1 2
-X- HERE IF RECORD IS TO BE DELETl
RIRTMnATF
Maie Femaie
ETHN.CCODE D D D D D D D
12 3 4 5 6 7
Transferring
□
3
- RESIDENTIAL ELIGIBILITY
STHEET
D □
PHYSICAL DATA
MT 59
LENGTH
DATE I I STATURf
DATE I WEIGHT
DATE I 1 HEMAT
O
HEMOG
FOR CHILD:
BIRTH WEIGHT
OR
STATE ZIP CODE COUNTS OR
RESERVATION
CODE
(HFIRHT 3 OR
IN CM
HOME TELEPHONE NUMBER
LBS KG
FINANCIAL ELIGIBILITY
infill V.
CATEGORY □ □ D □ □ □ □
12 3 4 5 6 7
1
DRIN '0 punnmi
NUTRITION AL ELIGIBILITY
NUTRITIONAL
LBS 02
IS CHILD BEING BREAST FED NOW
ilF YES, STOP HERE1
WAS CHILD EVER BREAST FED?
IF YES, HOW MANY WEEKS'
GRAMS
□ □
YES NO
□ □
□ □ □ □ □ □
PRIORITY 1 2 3 4 5 6
Pregnant
FOR WOMAN: □
1
Breastfeeding PP
D □
2 3
CERTIFICATION
•X- ONE-
CERTIFIED ELIGIBLE
CERTIFIED INELIGIBLE
□
□
WRITTEN STATEMENT OF REASON FOR INELIGIBILITY AND FAIR HEARING PROCEDURE MUST BE PROVIDED
WAITING UST
•X- HERE IF PLACING ON A WAITING LIST LJ
•X- HERE IF REMOVING FROM WAITING LIST LJ
SIGNATURE
Competent Prolessionaj Autnonty
rttwie copy — Stale Agency
•Www copy — Local Agency cue
Pink copy — Local Agency use
Transferring Participants
If you are entering a transferring participant who has never been assigned a
family and member number in your clinic, the form must have the name, residen-
tial, financial and nutritional boxes filled in. It is also the 1st visit and
box #3 for "Transferring" for you. Physical data may be updated when you
receive it from the transferring clinic. If you find your first entry was
inaccurate, you may also correct the certification information when you update.
X-41
VII
VERIFICATION OF CERTIFICATION CARDS
Purpose: To be used for transferring WIC participants, including mi-
grants. VOC cards are the same as WIC certification and may be used
for one certification period. VOC cards are to be accepted by local
agencies as proof of certification when presented by transferring
participants.
Who Completes: Local Agency Staff
State Agency Responsibilities: The State Agency will obtain VOC cards
from USDA and issue them to local agencies; maintain a record of the
numbers of each card received from USDA and a listing of the numbers of
the cards issued to each local agency; monitor local agency records and
supply of VOC cards during annual monitoring visits.
Local Agency Respcnsibi 1 ities:
The local agency wi 1 1 :
1. Maintain a log of VOC cards received and issued,
received from the State Office, their numbers will
log along with the date the cards were received.
When cards are
be entered in a
all participants who intend
in or out-of-state. When a
the participant's
Issue cards to
agency, either
transferring participant,
card, and the date issued are
issued for each transferring participant.
be noted in the family folders.
to transfer to a new
card is issued to a
name, number of the
entered into the log. One card is
Card numbers are also to
EXAMPLE: Cards #110010 through 110110, received xx/xx/xx
Number Issued To Date Issued
110010
110011
110012
John Doe
Jane Smith
Mary Smith
9/9/79
10/2/79
10/2/78
Make sure cards are issued in sequence, just as drafts are.
3. Return any VOC cards that are voided to the State Office.
4. Notify the State Office when the inventory of VOC cards is down to
approximately one month's supply.
transferring to your
the local agency that
lumber from that agency
i card is reported lost by a participant
ect, find out the name and address of t
inally issued it and obtain the old card ni
reissue a new VOC card. Record the new numl
If a card
projec
origi
and re..
name, new date
nie old card number from that agency
icvy VOC card. Record the new number, the participant's
issued and the old VOC card number on the log.
X-42
WIC Program
Verification of Certification
Certification No.
004456
Name
Date of Birth
Participant's Signature
Local Agency
Street Address and City
State
Teiepnone No.
AC-
Certification Record
Certification Dates
From: To:
Income Determination
Date:
Nutritional Risk Reason
Dates Food Package Issued
Local Agency Official's Signature
Local Agency Official's Name (Print or Type)
X-43
VIII. PARTICIPANTS RIGHTS AND OBLIGATIONS
Local Agency Responsibilities:
1. Local agency shall notify each participant, or parent/guardian of
each participant, at each certification of the following rights and
obligations:
Rules for acceptance and participation in this Program are the
same for everyone regardless of race, color, national origin,
age, sex or handicap.
You may appeal any decision made by the local agency regarding
your eligibility for the Program. The WIC staff will inform
you of the procedure for a Fair Hearing. It is illegal to
participate in more than one WIC Program at the same time.
The local agency will make health services and nutrition
education available to you and you are encouraged to partici-
pate in these services.
These statements are contained in the WIC Certification Record. At
each certification, applicant is requested to read these statements
and sign in the space indicated. If the participant cannot read,
the WIC Aide shall read the statements to him/her.
In addition, the WIC staff is to provide information on the types of
health services available, where located, how they can enroll and
why participation is important.
2. At each certification by the agency, each woman or parent/guardian
of infant/child shall read and sign the Participant Responsibility
Form, a copy of which is kept in the chart.
X-44
MIC PARTICIPANT'S RESPONSIBILITY FORM
Purpose: To provide written explanation of the participant's responsibilities
regarding program participation. Used to notify participant of the
consequences of misuse of WIC drafts.
Who Completes: WIC Aide and WIC participant sign the form.
How: At the initial visit, and each additional certification, parent or guard-
ian reads the sheet, or if unable to read, WIC Aide reads document to the
participant. Participant receives one copy to take home if desired; one
copy is signed by both participant and Aide and dated. This copy is kept
in the chart.
Format: The State Agency will provide a form containing the minimum information
needed. Local agencies may add to or combine the form with others,
provided that the minimum information is retained.
Monitoring Requirement: State Agency staff will monitor for presence of appro-
priate signed and dated Responsibility Form in the chart.
When: At initial and each successive visit, when transferred from one county to
another and the old form is unavailable, or when a new form is developed.
X-45
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)
MONTANA WIC PARTICIPANT'S RESPONSIBILITY FORM
nstructions: Please read this form and sign it on the back. If you do not under-
stand some part of it, please ask the person helping you to explain.
will notify the clinic if I cannot attend my scheduled WIC appointment and
understand that breaking appointments may cause me to be dropped from the program.
will notify the clinic if I change my address.
will live in the county served by the local agency where I receive WIC benefits.
will give accurate and honest information to WIC clinic personnel and be willing
to provide verification if necessary.
will report a voucher stolen or destroyed by fire.
will not use vouchers that were reported stolen or destroyed by fire.
understand that I am responsible for safekeeping of my vouchers before I cash
them.
will not receive vouchers from more than one clinic.
will cash the vouchers within 30 days of the issue date and never cash voucher
more than 30 days old.
will only purchase authorized food (or substitutions) authorized by the WIC
Program.
will buy only pasteurized, homogenized, fortified milk.
will not pay any cash for WIC foods.
will not take change from a WIC transaction.
will not make changes on the WIC voucher.
will not return WIC foods for cash or other items.
will sign the voucher after the checker writes the price on it and present an
dentifi cation to the checker if requested.
understand that the person who signs the top line of a voucher at the clinic,
must sign the bottom line of the voucher in front of the checker.
will shop only at authorized WIC vendors.
will ask the store manager for assistance or call the clinic if I have problems
redeeming WIC vouchers.
will not be verbally or physically abusive to any checker, vendor or agency
personnel. I will report any vendor or agency misconduct to the clinic or
clinic director.
X-46
I understand that I am responsible for the dollar amount written on the vouchers
that are issued to me.
I understand my child and/or myself are on WIC because we have met the age,
residential, financial and nutritional guidelines.
I understand my child and/or myself are "certified" eligible to receive WIC
benefits for up to six months for a child under age 5 or for women up to the
time the child is 6 weeks old if not breastfeeding or up until the child is 6-12
months old if breastfeeding.
I understand the certification process shall be repeated at the end of the above
specified time to determine continued eligibility for the program.
I understand the local agency will make health services and nutrition education
available to me and that I am encouraged to participate in these services.
FAILURE TO ABIDE BY THESE RESPONSIBILITIES AND/OR FEDERAL REGULATIONS
. COVERING THE WIC PROGRAM WILL NECESSITATE ACTION TO BE TAKEN BY THE WIC
CLINIC. THIS ACTION MAY RESULT IN DISQUALIFICATION OR TERMINATION FROM
THE PROGRAM.
YOU HAVE THE OPPORTUNITY TO APPEAL ANY DECISION MADE BY THE LOCAL AGENCY
REGARDING YOUR ELIGIBILITY FOR THE PROGRAM, WITH AN AGENCY CONFERENCE OR
FAIR HEARING. A HEARING FORM WILL BE SUPPLIED TO YOU UPON REQUEST FROM
YOUR CLINIC OR THE STATE WIC OFFICE, COGSWELL BUILDING, HELENA, MT 59620.
The above responsibilities have been explained to me.
Signature of Participant/Parent/Guardian Signature of Authorized WIC Staff Member
DATE
Signature of Participant/Parent/Guardian Signature of Authorized WIC Staff Member
DATE
Signature of Participant/Parent/Guardian Signature of Authorized WIC Staff Member
DATE
WIC IS AVAILABLE TO ALL PERSONS REGARDLESS OF RACE, COLOR, NATIONAL ORIGIN, AGE,
SEX OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, WRITE
IMMEDIATELY TO THE SECRETARY OF AGRICULTURE OR DIRECTOR, OFFICE OF ADVOCACY AND
ENTERPRISE, USDA, WASHINGTON, D.C. 20250
Revised 8/85
X-47
}
IX. APPOINTMENTS/SCHEDULING
Purpose: To schedule participant's or potential participant's next visit
for draft issuance, nutrition education and/or eligibility determina-
tions.
Who Completes: WIC Aide.
Procedures:
1. Schedule one appointment a month for draft issuance, approximately 30
days apart, but never more than one during a calendar month. Appoint-
ments for determination of eligibility may coincide with draft issu-
ance, or may occur between draft issuance visits. Appointments for
determination of eligibility must coincide with the first month's
draft issuance if the participant is notified of eligibility at that
time.
2. Keep a record of appointments in an appointment book, card file, etc.
Develop a simple system whereby appointment times may be readily
identified for participants that make requests for this information
because they have lost their appointment cards.
Appointment cards are available for local agency use from the State
Office.
When: At the end of each visit.
►
X-48
X. DETERMINATION OF ELIGIBILITY
Purpose : All these criteria are used to determine eligibility for WIC
Program services.
The applicant must first be a member of the population WIC serves:
Pregnant, postpartum, or nursing woman; child up to age five. The
applicant must meet financial, residential and nutritional criteria.
In addition, a pregnant woman must have confirmation of prenatal care
(see Health Services Section).
Explanation of Criteria
1. Population Criteria: Women are eligible during pregnancy, up to six
weeks following delivery or the termination of the pregnancy. Post
partum women are eligible up to one year if they are nursing.
Infants and children up to five years old.
2. Residential Criteria: Applicants must reside in the geographic area
of the local agency to which they are applying for WIC services. In
the' case of reservations or agencies operating programs in more than
one county, these areas may overlap county lines. In the event that a
participant resides in an area served by two WIC projects, they should
receive WIC where they receive their health services. Exceptions can
be made for hardship conditions which must be documented in the family
folder. For other circumstances see the Application Section.
3. Financial Criteria: Presently it is the State's policy that all local
agencies will use the Secretary of Agriculture's 185% of poverty
levels, as defined in Public Law 95-627 to determine financial eli-
gibility. No allowances are to be made for hardship conditions. New
guidelines will be provided to the local agencies by the State Office
annually. Current income guidelines and instructions for filling out
financial information on the Questionnaire-Certification Form are
found in the Application Section.
4. Nutritional Criteria: Eligibility is determined by a nutrition
assessment. (See Nutrition Section for further details.)
Who Determines Eligibility: Financial, residential and population eli-
gibility can be determined by the WIC Aide. Nutritional eligibility
is to be determined by a competent professional authority.
How Certification Data is Obtained:
A. Population Data: Use birthdate of the applicant, and pregnant woman.
Expected date of delivery can be obtained from Confirmation of
Prenatal Care information.
X-49
B. RESIDENTIAL ELIGIBILITY
Local Agency Responsibilities
WIC staff writes the applicant's address on the WIC Certification
form. WIC staff determines whether or not the participant or poten-
tial participant lives in an approved service area by reviewing
address information. ■ The approved service area is the area that is
outlined in the Agreement between the State and local agency. Usually
a service area is confined to the county or reservation in which the
WIC clinic is located. However, in the case of parent programs with
one or more satellites, their service area will include two or more
counties. If needed, the county may establish a policy on serving
persons out of their service area.
RESIDENTIAL ELIGIBILITY - Adjoining Counties
If a participant resides in an area served by a local WIC project, but
geographically close to a WIC clinic in an adjoining county, the
participant may choose to go to the adjoining county for WIC under the
following conditions:
1. The WIC clinic in the adjoining county has a slot available for
the participant;
2. The participant must receive health services in the adjoining
county and the adjoining county must agree to serve them;
3. The adjoining county must have vendor agreements with vendors
located in the participant's county.
If a participant resides in an area that is not served by a local WIC
project, but adjoins a county that does have a WIC project, the
participant cannot be served in the adjoining county unless they
receive health services in that county or if approved by the State WIC
Office on a case-by-case basis.
Participants residing in an area not served by WIC should be encour-
aged to actively seek WIC in their county by contacting physicians,
county commissioners, welfare departments, public health nurses, low
income advocacy groups, etc.
Interstate WIC participation policy is outlined in the Administration
Policy Section.
C. FINANCIAL ELIGIBILITY
Local Agency Responsibilities
Financial Information: Information is provided by the client on the
Financial Statement form.
Income guidelines for the WIC Program are set by the State WIC
office for all projects in the State within the eligibility
X-50
requirements mandated by USDA Regulations. These guidelines are
found in the Application Section.
For verification of income all participants/applicants must show
proof of income. (Please refer to Policy #85-6.)
Income check stubs or tax returns can be used for verification.
WIC staff use income guidelines below to determine whether total
income listed on the Financial Statement by the participant or poten-
tial participant are within the established guidelines. Persons who
mark on the Financial Statement Form that they are enrolled in specif-
ic federal programs do not need to provide additional financial
information, as they are automatically eligible for WIC. Participa-
tion in federal programs that are not listed must be approved by the
State Agency.
DEFINITION OF INCOME: Money earned before deductions for income
taxes, employee's Social Security taxes, insurance premiums, bonds,
etc., including: 1) Monetary compensation for services, including
wages, salary, commission, or fees; 2) Net income from self-employed
farmers and self-employed business persons (subtract operating ex-
penses from gross receipts); 3) Social Security; 4) Dividends or
interests on savings or bonds; 5) Income from estates or trusts; 6)
Net rental income; 7) Public assistance or welfare payment; 8) Unem-
ployment compensations; 9) Government civilian employee or military
retirement or pensions; 10) Veterans payments; 11) Private pensions or
annuities; 12) Alimony or child support payments; 13) Regular contri-
butions from persons not living in the household; 14) Net royalties;
and 15) Other cash income.
In determining eligibility, use either the family's income during the
past 12 months or the family's current rate of income, whichever is
the better indication of the family's need.
DEFINITION OF FAMILY: Group of related or nonrelated individuals, who
are not residents of an institution or boarding house, but who are
living as one economic group. Students who are temporarily away at
school should be counted as members of the family.
FOSTER CHILDREN: In cases where the welfare agency is legally respon-
sible for the child and the foster home is, in fact, an extension of
the welfare agency, the foster child is considered a one member
family. Welfare payments for the care of that foster child are
considered income of that one member family.
In cases where the welfare agency has placed a child in a permanent
home and/or subsidizes the child's adoption, the child is considered a
member of that household. The family size and total income of the
family determine the child's financial eligibility for WIC.
(
X-51
GRANTS AND SCHOLARSHIPS: Student financial assistance received from
any program funded in whole or part under Title IV of the Higher
Education Act of 1965, including the Pell grant, Supplemental Educa-
tinal Opportunity Grant, State Student Incentive Grants, National
Direct Student Loan, PLUS, College Work Study, and Byrd Honor Scholar-
ship programs, is excluded from income (Ref.: 7 CFP
246.7(c)(2)fiv)(L)).
X-51a
NUTRITIONAL ELIGIBILITY
Nutrition Data: Anthropometric (heights, weights, etc.) and biochemi-
cal data (hemoglobin/hematocrit) should be obtained if available from
the participant's physician, public health nurse, Well Child Confer-
ence records, or Headstart records. If the data is not available from
these sources, it can be gathered by the WIC staff. It is recommended
that duplication of data collection be reduced to the greatest degree
possible. For example if a child has had a hematocrit/hemoglobin test
within the last month at a Headstart Program, Well Child visit, or at
the physician's office, use this information for your nutrition
assessment.
Local agencies shall also develop a mechanism by which anthropometric,
biochemical and dietary data obtained by the WIC staff is shared with
these professionals and programs.
Identified nutritional problems are used by the competent professional
authority in assigning a client to a priority or rank ordering the
application within a priority or from a waiting list. The codes for
nutritional problems are given in the Nutrition Problems, Codes,
Criteria and References, a classification document provided by the
Montana Department of Health and Environmental Sciences and the
Montana Dietetic Association, for use in public health nutrition
services.
Instructions, methods and procedures for weighing and measuring the
length/stature of infants and children are those found in "A Guide to
Pediatric Weighing and Measuring," U.S. Department of Health and Human
Services, Public Health Service, Nutrition Division/CPHE, Centers for
Disease Control, Atlanta, GA 30333. November, 1980. Copy is avail-
able from the Montana State Department of Health and Environmental
Sciences.
Scales and length/stature measurement equipment standards are those
specified in Nutrition Surveillance, January-June, 1980, Centers for
Disease Control, U.S. Department of Health and Human Services,
U.S.H.H.S. Publication No. (CDC) 81-8295, pages 7-15.
Other guidance available and recommended by SDHES includes:
Growth Assessment of Children, Slide/cassette tape training
material available on loan from the Film Library, SDHES, Helena.
Rate Your Measurement Technique, slide/cassette tape training
material available on loan from the Film Library, SDHES, Helena.
Anthropometric Techniques and Their Application, Chapter 6 (page
69-92), by Gordon E. Robbins and Frederick L. Trowbridge, Nutri-
tion Assessment, A Comprehensive Guide to Planning Intervention,
by Margaret Simko, Catherine Cowell and Judith Gi 1 bride , Aspen
Systems Corporation, 1984.
X-52
XI. CASELOAD MANAGEMENT
Priority System for Nutritional Risk Criteria
Reference from 7 CFR 246.7 Certification. Federal Register, Volume 44,
No. 146, July 17, 1979.
The following priorities shall be applied by the competent professional
authority when vacancies occur after a local agency has reached its
maximum participation level, in order to assure that those persons ot
greatest nutritional risk receive Program benefits. State agencies may
set income priority levels within these six priority levels:
Priority I: Pregnant women, breastfeeding women and infants at
nutritional risk as demonstrated by hematological or anthropometric
measurements, or other documented nutritionally related medical
conditions' which demonstrate the person's need for supplemental
foods.
Priority II : Except those infants who qualify for Priority I,
infants (up to 6 months of age) of WIC participants who partici-
pated during pregnancy, and infants (up to 6 months of age) born of
women who were not WIC participants during pregnancy but whose
medical records document that they were .at nutritional risk during
pregnancy due to nutritional conditions detectable by biochemical
or anthropometric measurements or other documented nutritoinally
related medical conditions which demonstrated the person's need for
supplemental foods.
Priority III: Children at nutritional risk as demonstrated by
hematological or anthropometric measurements or other documented
medical conditions which demonstrate the child's need for supple-
mental foods.
Priority IV: Pregnant women, breastfeeding women, and infants at
nutritional risk because of an inadequate dietary pattern.
Priority V: Children at nutritional risk becauseof an inadequate
dietary pattern.
Priority VI : Postpartum women at nutritional risk.
B. Waiting Lists
If and when your caseload reaches the set maximum limit, you will
need to begin a waiting list. This instruction establishes guid-
ance concerning the use of waiting lists for Program applicants.
Waiting lists should provide a pool of viable applicants in order
to select the highest priority persons for participation when slots
become available. Section 246.7 (f)(1) of WIC regulations requires
that local agencies must keep lists of interested persons who visit
the Program when there are no funds available to provide benefits.
O
X-53
The waiting list must include the name of the applicant, the date
placed on the waiting list, address or telephone number, and
status. Individuals must be notified of their placement on a
waiting list within 20 days of their initial visit to the clinic.
It is not necessary to maintain a waiting list of all persons who
inquire about the Program. The list is a tool to ensure the place-
ment of the highest priority persons into the Program when slots
become available. If the local agency has strong caseload manage-
ment and knows that certain low priority individuals will never be
served, it is unnecessary to place them on a waiting list. For
example, if a local agency has reached maximum caseload and has a
sufficient number of Priority I and II applicants on its waiting
list to fill any likely vacancies, it is not necessary to place
Priority V children on the waiting list.
On the other hand, the waiting list must not be so restricted that
persons who might reasonably be expected to enroll later are not
enrolled. Fair hearings from an aggrieved applicant could result.
Similarly, if an applicant insists on being placed on the waiting
list, they must be processed. In any case, WIC staff should always
explain why placement on a waiting list is necessary and what it
means in terms of realistic possibilities of receiving benefits.
In order to place the applicant into the WIC Certification System,
Waiting List, the applicant must be completely screened and a
determination of el igibi 1 ity/ineligibi 1 ity made (see Application/
Certification Section, p. V-5). Only those applicants actually
certified eligible (meet categorical, residential, financial and
nutrutional criteria) can be placed on the system waiting list. As
local agencies will probably not be able to complete the entire
certification process for all who apply, selective screening must
take place prior to placement on the system waiting list. For
example, as given above, agencies with few openings and Priority I
and II individuals waiting to fill them, would not complete the
process for Priority V children. Using good caseload management,
some determination of an individual's chance to get on the Program
should be made before completing the screening process.
In those instances where the waiting list is comprised of entirely
low priority individuals (i.e., a.. Priority V children), then a
pool of certified eligibile applicants should be established based
on alternative criteria, such as greatest need within that priority
(i.e., known nutritional consideration, or on a first come, first
served basis among applicants whose nutritional status is closely
similar). In this case, local agencies may establish their own
procedures to determine which and how many applicants should be
screened. It should be kept in mind that some applicants may come
from referrals with nutritional and income data already available,
while others arrive with no referral data. There should be pro-
cedures to assure that those with no prior referral data can be
X-54
(
screened, as appropriate. Those applicants should be provided an
equal opportunity to be placed into the pool of candidates to be
considered for enrollment.
A final issue is how long waiting lists should be retained. We
believe the lists should be retained for a sufficient length of
time to allow the State Agencyto adequately review certification
procedures during monitoring visits.
The primary purpose of waiting lists is to maintain a pool of
interested applicants from which highest priority people can be
selected to actually participate when caseload slots become avail-
able. An important element of the system is to give benefits to
those who are in greatest need. But, the procedures for waiting
lists and screening should also be consonant with efficient and
effective management practices and should not become a futile
exercise in paperwork. The issue of'waiting lists is closely in-
volved in the overall issue of effective caseload management. We
encourage you to work with our agency health officials to establish
procedures which direct benefits to highest priority participants
in a workable manner.
X-55
XII. CHART INFORMATION
A. The following information needs to be included in a WIC Chart or in
a combined medical record available to the WIC staff:
1. WIC Certification Record and Financial Statement documenting
financial, residential and nutritional eligibility;
2. Participant's Responsibility Sheet;
3. Plotted Growth Grids or Weight Gain Grids;
4. Medical history information for identified risk factors or for
nutrition assessment;
5. Hematocrit or hemoglobin data;
6. 24-Hour Recall and/or dietary record and/or nutrition history
information;
7. Nutrition Care Plan -- Family or individual;
8. Documentation of referrals. Include name of the provider the
client has been referred to and the reason for the referral;
9. Documentation of follow-up to referral for nutrition-related
medical problems as needs and plans change;
10. Signed and completed Ineligibi 1 i ty/Fair Hearing Card if
dropped from the program;
11. Copies of WIC drafts for the certification period preceding
the current one, and for the current certification period;
12. Progress Notes.
B. The following forms need to be reviewed and updated at each certi-
fication (or more often if necessary):
1. WIC Certification Record (i.e., family member data if it
changes) ;
2. Financial Statement, if there is a change;
3. Participant's Responsibility Form;
4. Growth or weight gain grids;
5. 24-Hour Recall or nutrition history information;
6. Nutrition Care Plan;
X-56
1
7. Referrals and follow-up to identified nutrition-related
medical problems;
8. Progress Notes.
XIII. HEALTH SERVICES
The following services, by client category, must be made available by every
local agency. Local agencies do not have to provide these services directly,
but must document that they are provided in the WIC family folder or by cross-
reference to medical records.
I . Pregnant and Postpartum Women
A. Prenatal and postpartum care provided by a physician: Local
agencies must verify that a pregnant woman is receiving continuous
prenatal care by requesting a completed Prenatal Care Form before
WIC food drafts are issued to the client. A copy of the form must
be kept in the family folder.
B. Perinatal Classes: Local agency must document that client has been
referred to a prenatal class. Suggested content of these classes
is described in the Perinatal Manual available from the Montana
Department of Health and Environmental Sciences, and must be
conducted by a person approved by the Nurse Consultant of the State
Agency. Lamaze classes are acceptable.
C. Referral: Competent Professional Authority will refer client to
public health nurse or physician for follow-up on newly found
medical problems or other abnormal health status or health habits
requiring the attention of other agency or professional.
II . Infants and Children
A. Well Child Conferences
Well child conferences consist of public preventive health care
provided by a physician, nurse practitioner or other approved
health professional; or well child care provided by a private
physician. The requirements and standards for well child care are
those required by the Montana Department of Health and Environ-
mental Sciences, and available from the Bureau of Nursing, Montana
Department of Health and Environmental Sciences, or a Nurse Consul-
tant employed by the State Agency.
B. Coordination of Data Collection
WIC staff shall not perform anthropometric or biochemical tests if
recent information is available from physician, public health nurse
Head Start evaluation, EPSDT evaluation, well child visit, etc.
The WIC Regulations allow a one month (30 day) leeway in certifica-
. tion. This can be used to coordinate data collection with other f
agencies and professionals in the community.
X-57
I
Coordination of WIC and Other health Services
Whenever possible, for example, WIC and well child conferences
should be combined. The child can be examined by the physician or
nurse practitioner, receive a nutrition assessment by the diet-
itian, and receive fooa drafts from the WIC aide.
Maternal health data/history, infant and child health history/data,
nutrition assessments, family planning and health education data
should be combined into one medical record whenever feasible. This
enables continuity of health care of all programs offered by the
agency which the client participates in.
♦
*
X-58
I
FOOD DRAFTS RECORDS AND REPORTS
Forms and Instructions
1. Authorized Signature Form
2. Identification Card
3. WIC Draft Receipt Form
4. Monthly Draft Receipt Form
5. WIC Draft Voucher (See Application/Certification Section)
6. Draft Log Form
7. Stop Payment Request
8. Draft Exception List
9. Draft Deletion Procedures
10. Review of Food Instruments
11. Records Management
X-59
♦
AUTHORIZED SIGNATURE FORM
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)
MONTANA REQUEST FOR AUTHORIZED SIGNATURE CARD
WIC PROGRAM:
DATE OF REQUEST:
TYPED SIGNATURE WRITTEN SIGNATURE
1 . Name
Title
2. Name
Title
3 . Name
Title
*
Any WIC employee issuing WIC vouchers must have an authorized signature
card. Inform the state office of any changes in WIC personnel.
Send this form to: State WIC Office
Health Services Division
Montana Department of Health and
Environmental Sciences
Cogswell Building
Helena, MT 59620
At the onset of a program, and anytime thereafter when there is an addition of
an authorized staff person authorized to sign WIC drafts, send this form to the
State Office, keeping a copy for your files. DO NOT re-list those persons
already authorized when sending in additional names.
When a staff person resigns, or is otherwise no longer authorized to sign WIC
drafts, notify the State Agency of the deletion of the staff person from the
authorized signature list.
X-60
IDENTIFICATION CARD
STATE OF MONTANA
DEPARTMENT OF HEALTH & ENVIRONMENTAL SCIENCES
WIC PROGRAM
Jane Doe
This is to certify that.
whose signature appears hereon is employed as a staff member of the
Montana WIC Program through the local health agency and is hereby au-
thorized to perform any and all duties delegated to such employees under
the laws and contracts of the State of Montana.
\ Coordinator State WIC Program
_-L
Coordinator State WIC Prograrr
Dated at Helena. Montana.
ir. State WIC Program _
June 19, 1987
Tnis identification becomes void one year from date of issue or at termina-
tion of employment by the WIC Program — at which time it must be surren-
dered
_22S_
\
rc
The State Office will issue numbered identification cards to local agencies upon
receipt of the above form. These cards are to be returned to the State Office
immediately when an employee resigns or is no longer authorized to sign WIC
drafts. (The card expires one year after issuance.)
Identification of registered dietitian is by their registration number assigned
at the time of passage of the Registration Examination. The Montana State
Department of Health and Environmental Sciences obtains this information on a
periodic basis from the American Dietetic Association, and on a case basis upon
request.
X-61
3. WIC DRAFT RECEIPT
WIC DRAFT RECEIPT
I certify that on , I received and physically
inspected the following WIC vouchers numbered
through _J . The following draft numbers are missing:
I would like to make the following comments about this shipment of
vouchers :
Signature
Title
WIC Program
Date
Return this form to: State WIC Program
Health Services Division
Cogswell Building
Helena, MT 59620
The WIC Draft Receipt Form is to be filled out every time an agency receives
drafts from the State Office, and the completed form should be sent to the State
Office no later than 5 days after receipt of the drafts.
Upon receipt of drafts, WIC aide will count packages received, multiply by
number of drafts in package and spot check packages (particularly the last
package, which may not be full) for accuracy in numbers listed on packages by
printers. This is important, as printer errors have resulted in issuing drafts
out of sequence in the past.
Record numbers on the Draft Inventory Report.
NOTE : KEEP ALL UNISSUED DRAFTS IN A LOCKED VAULT, FILING CABINET OR DRAWER.
ONLY AUTHORIZED PERSONNEL MAY SIGN WIC DRAFTS.
X-62
MONTHLY BLANK SIGHT DRAFT INVENTORY REPORT
ITATt O* MONTANA
OEPARTMcNT OF hialTh - MIC PROGRAM
MONTHLY BLANK SIGHT DRAFT INVENTORY REPORT
LOCAi-reL
MK Ma r
aa saaaa
A Scftf Dr*/S on Amd «f beginning of month. No. Thru Quantity
3. S>cht Drafts received Curing month.
C S>pnt Drafts available during month. (A * B)
D. Sight Drafts issued or voioed during the montfi No. .
. Thru Quantity _
. Thru Quantity^
For A, B, t, D, Subtract nuroers, add 1 and record in quantity space.
£ Balance of Sight Drafts on hand at end of
month. (C - Dl
, Thru i.Quanr/ry_
As a toss check, subtract D from C and you should get E.
/ certify that I have physically inspected the blank sight drafts on hand as of the last wonting
cay at the month o/_ J— * thai the sight draft numbers ■ndicsnd
too** and the total number of sight drats on hand ant correct
'
a. Instructions
1. The Monthly Blank Sight Draft Inventory Report is completed for
each month by the 10th working day of the following month. The
original is mailed to the State Office, and a copy is retained in
your files. If you have more than one batch of drafts, report
each batch on a separate form.
2. Fill in month and clinic number in upper right hand corner.
3. For Parts A, B, and D subtract first number from second number,
add 1 and record answer after "Quantity."
4. As a cross-check for E, subtract D from C. The answer should
match the number following "Quantity" in E.
Don't forget to add "1" where indicated on the form.
<
X-63
•
Inventory Control
a. One staff person in each clinic must be designated as "inventory
control person" whose responsibility it is to:
1. Complete the Monthly Sight Draft Inventory Report
2. Assure the safe keeping of the blank drafts
3. Issue drafts and log sheets to other WIC staff, where appropriate
(see below)
4. Make sure log sheets are accurately completed and mailed to the
State Agency on a daily basis.
5. Make sure all drafts are accounted for by issuing drafts for use
in sequence.
b. All unissued drafts must be kept in a locked vault, filing cabinet or
drawer at all times. When in use by authorized staff, small amounts
(no more than the anticipated day's usage) may be maintained at the
aide's desk.
c. The procedure for the issuing of drafts for use is:
1. In clinics with more than one person issuing drafts during the
day, the inventory control person will issue drafts to authorized
staff in a batch of 30 drafts. To each batch of 30 drafts
issued, the inventory person will also clip a log sheet with the
number of the first draft in the batch appropriately filled in.
Ordinarily only one batch of 30 drafts will be issued to staff at
a time. In a large clinic where aides might issue more than 30
drafts in a day, two batches may be issued at a time. When the
inventory control person issues a batch of drafts to a staff
person, the inventory control person will fill in a written draft
log that will include the date, time the drafts &re issued, to
whom, and draft numbers assigned.
2. The aide will take the batch of drafts and log sheet and place
the drafts in a drawer or some other place in their work area.
After a set of drafts have been issued to a family, and before
the next appointment, the aide will fill in the log sheet with
the necessary information. Drafts will be listed on the accompa-
nying log sheet as they are issued. If there are not enough
drafts and spaces left on the log' sheet to take care of the
number of drafts that will be issued to the next family, the aide
should return to the inventory control person and obtain another
batch before the client is served. When a log sheet has been
completely filled in and all 30 drafts accounted for, the aide
will return the log sheet to the inventory control person, and if
necessary pick up another batch of 30 drafts at that time.
3. The inventory control person will note the time the log sheet was
returned on the draft log. The inventory control person will
X-64
make sure that the log sheet has been completely filled in (see
instructions on page VI- 11 ) and all 30 drafts are accounted for
before issuing another batch of drafts.
4. If at the end of the day not all of a batch of drafts has been
issued, the aide will clip the unused drafts to the log sheet and
return them to the inventory control person. The inventory
control person will note the numbers of the drafts returned and
the time returned, on the draft log and properly store them. If
it is not the end of the week, or the end of the month, the
unused drafts and log sheets from the day should be reissued and
used first the following day. An aide may thus be issued a
partial batch and a full batch of 30 drafts in the morning. When
the log sheet from the day before is completed, it is taken to
the inventory control person.
5. On the last working day of the month, or at the end of the week,
all log sheets only partially filled in will be Sent to the State
office along with the rest of the day's log sheets. The partial
batch of drafts that is left will be reissued the next working
day with a new log sheet containing the beginning number. The
inventory control person will have a line drawn through the
unneeded lines on the log sheet so that the number of lines
available matches the number of drafts in the partial batch.
When the batch is used and the log sheet filled in, the aide will
take the log sheet back to the inventory control person as noted
above.
6. At the end of each working day, the day's log sheets will be
verified and sent by the inventory control person to the State
Office. The verification will include making sure all drafts
issued for the day are accounted for anG all information on the
log sheets has been completed, before placing log sheets together
in an envelope and mailing.
7. Because drafts will only be in sequence within a log sheet, the
inventory control person will have to be careful to assure that
drafts are issued in order and all are accounted for. Drafts
should be issued for use as close to in-sequence as possible. At
the end of the month the inventory control person in larger
clinics should try to issue only enough drafts to last to the end
of the day so that there are if possible no partial batches left
at the end of the month. If there are, the Monthly Sight Draft
Inventory Report will be more complicated to fill in.
'
X-65
WIC VOUCHER
□
O
1
STATE OF MONTANA
WIC PROGRAM
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PAY TO THE ORDER OF
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PAY EXACTLY
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MUST DEPOSIT WITHIN 60 OA*S "0»
VOID
DATE OF ISSUE £
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WIC CUSTOMER SIGNATURE Q
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VOID
WIC CUSTOMER COUNTERSIGNATURE
INSTRUCTIONS FOR COMPLETING THE WIC DRAFT/VOUCHER
Purpose: To ensure that WIC drafts are uniformly and correctly filled
in by the local agency and vendors.
Local Agency Responsibilities:
Local agency personnel who are authorized to sign WIC drafts complete
the necessary portions of the draft in ink as follows:
1. On the first set of drafts issued to a family for the month,
indicate the numbers of women, infants and children for whom the
drafts are issued.
EXAMPLE: 1 Woman
Infant
2 child
Complete the food and quantity list on each draft for the family
under the guidance of the nutrition personnel of the local agency
and in accordance with nutrition and food package policies of
U.S.D.A. and the State Office. Where applicable, participant
will state preference for brand of cereal, juice, etc., and this
will be entered on the draft. Food will be listed on drafts in
accordance with instructions in the Food Package Section. Cross
out the cost line for any foods not authorized for the partici-
pants).
Complete the estimated cost for each food authorized on the
draft. Estimated cost is to be obtained from Grocer's Price
Lists, updated quarterly or monthly if necessary. Total each
estimated cost and enter it as the "Estimated Purchase Price."
X-66
4. Enter today's date as the date of issue ("Good From") and the
date 30 days from today's date ("To"). Example: GOOD FROM July
6, 198_ TO August 6, 198_.
5. Enter the vendor's name in the "Pay To the Order Of" box. The
participant should be given the opportunity to designate the
vendor.
6. The authorized WIC staff person signs the draft where indicated,
and obtains the participant's signature as indicated on the
draft. The participant should sign the draft in the presence of
the WIC Aide, unless the draft has been mailed. See procedures
for mailing of drafts, page X-69 (below).
7. The participant is given the original draft(s) after completion
and signing. The WIC staff fill in log sheets, file the yellow
copy in the participant's file, and send the leg sheet daily to
the state office.
Vendor's Responsibilities:
1. Vendor's staff totals the WIC foods listed on the drafts, check-
ing substitutions, etc. (see Section on Vendors). The actual
purchase price of the foods is then written in by the clerk in
the "Pay Exactly" box. If the actual purchase price exceeds the
maximum value printed on the draft or is more than 10% above the
Estimated Price, the vendor cannot accept the draft ana must(
advise the WIC participant of the vendor's options outlined in
the procedures for Computerized Exception List (10% over Estimate
List) on page 2(k) of Vendor Agreement.
2. If the draft is correctly completed at the local agency the
vendor has the participant counter-sign the draft on the line for
"WIC Customer Countersignature." If the participant or par-
ent/guardian is unable to come to the store, he/she must counter-
sign the draft and send a signed note with his/her designee
granting permission for that party to cash the draft.
3. The vendor has 60 days from the date of issue of the draft to
deposit the draft. (Refer to date listed on draft "Good From
"•)
MAILING WIC DRAFTS
Purpose: To provide guidelines for the mailing of WIC drafts to
participants when circumstances do not allow them to pick them up at
the local agency.
When: WIC drafts may be mailed to individual participants for the
fol lowing reasons: Inclement weather, illness, imminent childbirth,
inability to get to the project during its hours of operation, extreme
distances to travel, other reasons as determined valid by the WIC
Project Director or the WIC designee, and approved by the State Office
(see No. 5 below).
X-67
How: Drafts may be mailed to participants only under the following
conditions:
1. Only enough drafts should be mailed to cover the period until the
participant can again come into the project.
2. Drafts are mailed certified or registered mail if possible.
3. Mailing is discontinued when hardship is resolved. Mailing of
drafts should never occur for more than three months in a row, as
the participant must return to the clinic after that time to
receive health and nutrition education services.
4. Reasons for mailing the drafts must be documented in the partici-
pant's file for each relevant month. Also, the appropriate draft
numbers must be identified on the daily log sheet by an asterisk
(*) and a notation of why these drafts were mailed.
5. Approval must be sought from the State Office for reasons other
than those listed above.
6. Should a local agency desire to mail drafts on an agency-wide
basis, prior approval must be sought from the State Office. For
example, a small county open only 4 days a month would need to
mail drafts if there were blizzards during those 4 days and they
could not reschedule participants within that month.
X-68
SIGHT DRAFTS ISSUED LOG
^TATE OF
MONTANA
OFP6BTMSNT OC Hi AH M 4
(NV.fiONMfMAL SCIENCES VL^moMh' da- , Tf*« 1
CLINIC NAME -Zl^
su;in mt\ns issckij i.ch;
'Li-i mi,! > i pmeram lor Wumm.
Clime Numftei
L, C? ,J ' Numoei Ol drafts on this diop "«■ ^
OMATT | | VENDOR
hUMBFA j 1 COOt
(„„ c.nl. 1 "Ol0| ! NUMBEB 1 IMEMaEB| | ISSUC01O «AM£
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TOTAL /7J\
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Signing* ot Local wiC Qtiict*
TE_J^_ P„.£2o((^
General
1. All drafts issued must be recorded on log sheets as they are
issued.
2. Write or print so it is easy for another person to read.
X-69
3. Each log sheet must be totaled separately. Do not carry sub-
totals from one sheet to the next.
4. Do not staple log sheets together. Do not staple anything except
adding machine tapes to log sheets. Log sheets may be folded
together for mail ing.
5. All log sheets must be filled out in duplicate.
6. Submit the log sheet(s) daily to the State WIC Office, sending
the original to Helena and filing the duplicate in your office.
7. Log sheets must be completed at the time the drafts are written
(issued to a client) .
Instructions (the numbered items below refer to the numbers indicated
on the log sheet pictured above)
1. Enter the month, day and year for which the log sheet is being
prepared.
Example: 0/7 2/1 8/9
Month Day Year
2. Clinic Name: Enter name of agency (Yellowstone County, Flathead
Reservation, etc.).
3. Clinic Number: Enter the three-digit number issued to your
clinic (601, 321, etc.).
4. Number of Drafts : Record the total number of drafts on the page
(30, 22, etc.).
5. Draft Number: Enter all draft numbers here, including those that
are voided.
Draft numbers shall be entered in consecutive order, always in
sequence, starting with the smallest number.
The first entry on the log sheet must be the complete draft
number. Thereafter, only the last 2 digits of each draft number
is necessary, unless there is a change in any of the first 3
digits. Then the entire draft number must be entered.
Always use the complete 5-digit draft number for the last entry
on the page.
Use a bracket and arrow in the empty spaces to indicate to the
key punchers that the first 3 characters of the last complete
number are to be repeated until there is a change.
X-70
EXAMPLE:
STATE OF MONTANA
DEPARTMENT OF HEALTH i
1 ' '|
HELENA. MONTANA 59620
"CLINIC NAME:
| MONTH | DAY | TEAR j
SIGHT DRAFTS ISSUED LOG
Suuplemenl.il tund hntrjm fur Women.
Inlanls and Children i\\ |C) «
.Clinic N
umber ! ' II
dumber ol drafts on this pa
DRAFT 1 IVENDORj 1 DRAFT AMOUNT , !
NUMBER | | CODE | 1 DolUrs Cents | , °
FAMILY
NUMBER
IMEM8ER
ISSUED TO NAME '
iy 3 a*? £"
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6. Vendor Code: Make entries in this column in the months of
January, April, July and October.
i. Always begin the data entry with the first full clinic day
of operation in the time period designated.
Enter the assigned vendor code for each draft. Don't use
arrows, ditto marks or other short cuts.
n
iii. End the data entry with the last full clinic day of opera-
tion in the time period designated.
7. Enter the estimated purchase price of the draft.
8. Void: Indicate a voided draft with a large red "V".
9. Family Number: Enter the assigned Family Number for each draft.
Zeros need not be entered in spaces before family numbers.
X-71
»
i
10. Member: Enter the assigned member number for each draft. Do not
enter zeros before member numbers. Enter only one member number
per space.
i. If there are more drafts than family members, repeat any
member's number. Member number spaces must be filled in for
all drafts issued. Do not list a number for a family member
who did not- receive a food package, for example, a breastfed
infant.
ii. Issue enough drafts so that each member of a family receiv-
ing a food package can be listed in a member space. For
example, if there are four family members receiving a food
package, issue at least four drafts for the family.
11. Name: Enter client's name.
Consecutive numbers issued to the same person may be indicated by
a ditto mark in the "issued to: NAME" column.
If a draft has been voided, write in the word "VOID" in red. If
a client's name has already been entered, write the wore "VOID"
over it in red.
12. Total Amount: Total the dollar amounts of the recorded drafts.
Submit two adding machine tapes for each log sheet (one for the
total of amounts from yellow draft copies and one for the total
of amounts on the log sheet). Staple both tapes to the top right
hand corner of the log sheet.
13. Comments : Use this space for comments about drafts on this log
sheet, especially for explaining voided drafts..
14. Signature: The signature of the person completing the log sheet
must be entered here. This. should be the aide who issued the
drafts listed.
15. Date: The date the log sheet was completed must be entered here.
16,17. Enter the total number of log sheets submitted each day.
Example: Page 1 of 21 .
)
X-72
8. STOP PAYMENT REQUEST
(
Section
STOP PAYMENT REQUEST
A & B to be completed by local
agency
SECTION A
PROJECT NO
PROJECT NAME
PHONE NO.
COMPLETED BY
REQUEST PAYMENT BE STOPPED ON THE WIC DRAFT DESCHtBED BELOW
DRAFT NUMBER f
DATE OF DRAFT ^
AMOUNT
►
PAYEE f
DATE REQUEST RECEIVED
l REASON FOR
f STOP PAYMENT
►
SECTION B
DRAFT REISSUED
DATE REISSUED'
YFI
DRAFT NO
AM
OUNT
SECTION C
1
To O* comp »!(']
by St*
AID
n Agency
OATE LOGGED
ORIGINAL PAID YES
NO
DATE
AMOUNT
NO:
DATE PAID
AMOUNT
COMPLETED EV:
DA
TE
(State Agency Personnel)
When Used
a. When client or vendor reports an issued draft stolen or destroyed by fire.
NO OTHER REASONS ARE ALLOWED.
Instructions
The Stop Payment Request Form is filled out in duplicate, sending the original
to the State Agency on the same day. Information is recorded in the client's
folder, and a copy is filed in the local agency "Stop Payment" file.
Fol low-Up
The local agency will be notified by the State Office if the stop-payment draft
has been cashed. If the client has cashed the draft, he/she will be notified,
as described in Section VII, page 4, and information documented in the family
folder. Sanctions will be applied as described in Section VII, page 4 of this
Manual.
Re-Issuance of Stop-Payment Drafts
Drafts shall not be reissued routinely. If a draft is destroyed by fire or
stolen, a once-only re-issue is appropriate.
Drafts should only be re-issued if the participant is not due to be issued
drafts for the next month, e.g., if the participant reports four weeks of drafts
lost and has only two weeks until the next appointment, only two weeks worth of
food drafts should be re-issued.
X-73
9. DRAFT EXCEPTION LIST
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WlC)
Montana Draft Exception List for Month of
Clinic Code
CI Inlc Name
The State Office will send a computerized exception list printout to local
agencies, listing drafts from each project which exceed the 10% estimate list.
Local agency staff will then fill out the above form, listing each draft on the
computer list.
PROCEDURES
I. Local Agency Responsibilities:
A. Explain the disposition of each voucher listed on the printout re-
ceived from the State Agency, using the draft exception list (DEL)
form provided by the State Agency.
B. Send a copy of the DEL to the State Agency each month.
C. At the end of every quarter, determine which vouchers are store
errors. List aJT errors for each Vendor on a separate "voucher
collection memo" and send the white and yellow copies to the State
Agency. (List alj of the store-error vouchers even if the total dollar
amount is not $10.00. )
X-74
D. Maintain records of draft exception activities for use in vendor
relations and communications. (Your yellow draft copies must be kept
until all exceptions/collections are resolved.)
II. State Agency Responsibilities:
A. Send a list of draft exceptions to the local agencies on a weekly
basis.
B. Drafts determined to be collected will be pulled by the State Agency
and copies made. (These are store-generated errors of 10% or more
above the estimated cost of the foods.)
C. If the total is sufficient to collect ($10 total, or more than $3 on
one draft), the State Agency will forward the information along with a
copy of the draft to the Fiscal Services Bureau, DHES, for collection.
D. One copy of the draft will also be retained by the State Agency and
can be sent to the local agency upon request.
10. DELETION PROCEDURES
The State Agency will send a computerized deletion list of all drafts
outstanding 60 days or more. Local agency will enter name of client to the
right of draft number on deletion list, and note in client's file progress
notes.
\
If client is not cashing all the drafts because of surplus of certain
foods, a reduction of the food package should be considered for that
client.
11. REVIEW OF FOOD INSTRUMENTS
The State Agency has implemented the following procedures to detect errors
in cashing WIC vouchers:
1. The office clerk at the State Agency manually reviews a one day
sampling of vouchers each week for altered prices, dates, missing
signatures and altered vendor names. A quick follow-up is initiated
with local agencies to resolve any problems.
2. The Core Accounting System automatically notifies our accounting
technician when vouchers are cashed outside the valid redemption
dates. All vouchers cashed outside the date parameters are listed as
unmatched claims on weekly printouts. Appropriate action is imple-
mented with local agencies to resolve discrepancies.
3. If a voucher is lacking purchase price information or vendor identi-
fication, the banking system will not accept the voucher. Banks will
return incomplete vouchers to vendors who neglect to fill in the
proper endorsement and purchase price. Montana's voucher issuance
system is considered vendor specific. Local agencies are required to
list a qualified vendor on each voucher prior to issuance.
X-75
The vendor reporting system detects errors and abuse in the voucher
redemption cycle by selective clinics or separate vendors within a
clinic. The vendor module provides the following information:
a. Vouchers where paid amount exceeds estimated amount by 10% or
more.
b. Vouchers redeemed for an exact dollar amount (i.e., no cents).
c. Vouchers where paid amount exactly equals issued amount.
d. Vouchers redeemed for more than the maximum.
e. Total vouchers issued per vendor and their cumulative issued and
paid values.
X-76
12.
1.
Records Management
Unless otherwise noted, records must be mana
Copy Kept On For
File at How
Record Name Local Agency Long?
Log Sheets Yes 3 yrs.
ged as follows:
Confi- Safekeeping
dential Required?
Yes No
i
Deadline for
Submission
to State Aqency
Daily
2.
Stop Payments
Yes
3 yrs.
Yes
Yes
As soon as reporte
3.
Voided Drafts
Yes
3 yrs.
Yes
Yes
As soon as reporte
4.
Draft Report
Yes
3 yrs.
No
No
5th working day o1
following month
5.
Draft Exceptions
Yes
3 yrs.
Yes
Yes
Monthly & Quarterl
6.
Voucher Carbons
Yes
At least
6 mo.
Yes
Yes
N/A
7.
Vouchers
Yes
Until
used
No
Yes
N/A
8.
Participation
Report
Yes
3 yrs.
No
No
N/A
9.
Expenditure Report
Yes
Local
Policy
No
No
15th working day c
following month
10.
Vendor Letters
Yes
3 yrs.
No
No
Quarterly
11.
Vendor Agreements
Yes
3 yrs.
No
No
When renewed
12.
Vendor Monitoring
Checkl ist
Yes
3 yrs.
No
No
When renewed
13.
Racial/Ethnic
Yes
3 yrs.
No
No
N/A
14.
Inventory Worksheet
Yes
3 yrs.
No
No
December 31
15.
Contracts w/DHES
Yes
3 yrs.
No
No
July 31
16.
Budget Requests
Yes
3 yrs.
No
No
April 30
17.
Carry-Over Expense
Yes
Local
Policy
No
No
w/Oct, Nov, & Dec
Expenditure Reporl
18.
Agency Corres-
pondence
Yes
3 yrs.
No
No
N/A
19.
Signature Cards
Yes
Until
staff
termin-
ation
No
Yes
Upon staff change
20.
Family Folders
Yes
3 yrs.
Yes
Yes
N/A
21.
Nutr. Ed. Plan
Yes
3 yrs.
No
No
22.
Agency Evaluation
Yes
1 yr.
No
No
N/A
23.
Self-Monitoring
Yes
1 yr.
No
No
Upon receipt
24. S.A. Monitoring
DT/war-013f
Yes
1 yr,
No
No
30 days after
report
k
X-77.
>
FAIR HEARING PROCEDURES
I. FAIR HEARING PROCEDURES
II. ABUSE/FRAUD
X-78
I. FAIR HEARING PROCEDURES
TIME SLQ11SCE FOR FAIR HEARING
tzZ-2H PARTI CI FAST STATE LOCAL AGENCY
p:-.:::rvR£
Participant notified Farticirant has 60 Local Agency must
ineligible for VIC days to request prc\ :o* participant
benefits. . fair hearing.* with fair
hearing card &
fol low procedures
out 1 ined in Policy
& Frocedure Manual .
Participant requests Participant will receive Local Agency ob-
fair hearing to 10 days written notice tains legal co-iasel
State Agency within of time and place of to represent program
60 days. fair hearing within 3 at hearing within 3
weeks of request. working days of re-
ceipt of hearing
request.
Fair hearing is held Within **5 days of State Agency seed (to
in county unere original request participant
participar.t resides. participant will withic 45 days)
receive decision by decision by
hearings official hearings official
Participant appeals Request must be made to State Agency
decision. District Court within 30 notifies Legal
days of receipt of Division of
uritten notification appeals request.
of decision.
"Tr.e participant who is terrtiniated during a certification oeriod and requests
a fair hearing within 15 cays of termination will cor.tinue receiving benefits
until a hearing decision is made.
Fair Hearing procedures are for the purpose of providing any individual denied
participation in, suspended or terminated from the WIC Program an opportunity to
challenge those actions. The above chart outlines steps and time limits to be
followed, and are also stated on the Fair Hearing Card, given to each applicant
declared ineligible (see page V-5).
A. A 11 requested fair hearings shall be conducted by the State Office, in
accordance with Section 246.23 of the WIC Regulations, FNS Guidelines, and
Title 2, Chapter 4 of the Montana Codes Annotated. The hearing officer's
decision shall be binding on the State Office and local agency.
1. If the decision is in favor of the appellant, Program benefits shall
begin for an appl icant and continue for a cl ient within the 45- day
1 imit.
2. If the decision is in favor of the agency, any continued benefits
shall be terminated, as decided by the hearing officer.
B. Al 1 records of the hearing shal 1 be retained in accordance with Section
246.16, WIC Regulations, and shall be available to the appellant or his
representative.
k
X-79
II. CLIENT ABUSE/FRAUD
A. Definition of Abuse (one or more of the following)
1. Deliberate misrepresentation of income, residential or nutrition-
al eligibility data to obtain benefits.
2. Sale or exchange of food or food vouchers.
3. Receipt of cash or credit from vendors for purchase of unau-
thorized food or other items of value.
4. Alteration of food vouchers, redemption of food vouchers reported
lost or stolen, cashing vouchers after the 30-day limit has
expired.
5. Dual participation.
6. Physical abuse, or threat of physical abuse, of clinic or vendor
staff.
B. Local Agency Responsibilities
1. The agency is to be alert for possible client abuse. When abuse
is detected or suspected, the agency must document as completely
as possible, including a narrative account of how abuse was
detected and copies of any relevant vouchers or other documents.
This information is entered on the WIC Participant Fraud Form,
and discussed with the client. The client is given an opportuni-
ty to make a statement, but in no case should be forced to. If
client will not, or cannot sign a statement, note this on the
form.
ja ItfUKf Aaae
Htf CHatc Contact Person _
•i-T(lf>4rfl AAra
wotai **ported
yq 1-AHtlclfClT 1KAU0 1UKM
Clinic Sttt
-j*—:ji-;"rr: •;■.-* : ^T=.
10JC+*' ri
Dlte of Issue Estjwgted Cost of Voucher Actual Cost of Voucher ■'
>#-~ >:.-— «,v
' _ •.->•" v=v*.*fc -— '
fcetatl Sure
Address
TYPE gf FRAUD
!~~1 ftrceWed change from WIC purchase.
f
*~"1 trewieed "ore VIIC food tfiAn authorized. -
I stolen checks.
I checks reported lost or stolen."
Cwl participation ,-
Ouier l_
Received unauthorized foods from
WIC purchase.
Returned UIC foods for cash.
Deliberate alteration of food instrument
Knowingly falsified eligibility
information.
AtucA lerox copies of checks and other documents supporting case.
0.1IIC STATDCHT:
r
Signature ol Authorized Clinic Personnel
Signature of Participant
«■*'»■»■: ««P Participant on probation. .
_ _ ui-oo participant.
A**P participant on program until SOHES resol.es
seep participant on program, e.iaence does not support fraud allegation.
STAO OPICS n,; cTATt y|C PROGRAM COORDINATOR
• "OmTAhA STATE WIC PROGRAM '• •
' MATERNAL AM CHILD HEALTH BUREAU
" .. STATE DEPARTMENT Of HEALTH
COGSWELL BUILDING ~s ' " '
rtXEKA. MONTAAJk S9601
X-80
2. If evidence shows fraudulent activity on the client's part,
agency staff will warn the participant in writing of the conse-
quences of continuing fraudulent activity; suspend client for up
to 3 months; or remove the client from the Program, depending on
the circumstances. Client shall then be given an opportunity for
a Fair Hearing.
3. Dual Participation: All clients receiving drafts are compared
for birthdate, sex, last name, and first four initials of the
first name. When a potential case of dual participation is
identified, information about the situation, including drafts
issued, clinics where drafts were issued, dollar amount, county
of client residence, etc., is included in the report.
State Agency staff screen out obvious inconsistencies like clinic
errors and twins. Then an initial telephone contact is made with
the local agencies involved to further screen out naturally
occurring similarities.
Once potential dual participants are clearly identified, the
local agency is notified and steps outlined in paragraph C below
are implemented.
Participant Sanctions
(1) Immediate disqualification from the Program for three months for
knowingly and deliberately misrepresenting circumstances to
obtain benefits (income, nutritional, residential eligibility);
sale or exchange of food or food instruments; dual participation.
(2) One warning letter (failure to comply immediately, or to repeat
the abuse later results in disqualification for three months) ,
for alteration of food vouchers, redemption of food vouchers
reported lost or stolen, cashing vouchers after the 30-day limit
has expired; receipt of cash or credit from vendors for purchase
of unauthorized food or other items of value; physical abuse, or
threat of physical abuse, of clinic or vendor staff.
(3) A total of two disqualifications at any time during one certi-
fication participant requires termination from the Program.
(4) Before disqualification and/or termination from the Program for
alleged abuse, that participant shall be given full opportunity
to appeal as set forth in 7 CFR 246.23 and Part IV, Section Three
of the Plan.
(5) The State Agency shall refer participants who abuse the Program
to federal , state or local authorities for prosecution under
applicable statutes where appropriate.
X-81
FRAUD HEARING MEMO
fTO: (VIC Complainant) DATE:
FROM: State VIC Office
[SUBJECT: Hearing Requested for (state reason)
As you have requested, a hearing has b«_en scheduled for you on the question of
iVIC benefits. This hearing is scheduled for (time) at (place)
The hearing official uho will conduct the hearing will be (name)
, (title) t The hearing will take place as follows:
1. The local VIC office will present its reasons for denying you
benefits .
2. You and/or your representative (lawyer, friend, etc.) will present
the reasons why you believe you are eligible for VIC benefits.
Both you and the local VIC project may call witnesses and present documents
and other papers to be made a part of the hearing record. Witnesses called
may be questioned, examined, or cross-examined by both parties (you and the
local VIC project). The hearing official will make sure that both parties
have the opportunity to present evidence and arguments, and to respond to all
evidence and arguments presented.
All exhibits (documents, papers, etc. presented as evidence) will be marked to
indicate who is offering them. All exhibits will be kept by the State
Department of Health and Environmental Sciences as part of the hearing record.
The hearing official may ask that you have another medical assessment or
evaluation done by someone agreeable to both you and the local VIC agency.
Should this happen, VIC will pay for it. VIC will also pay for all other
costs of hearing except for the cost of your attorney should you decide to
have one.
The hearing will be tape-recorded and a written record made. The record will
be kept by the State Department of Health and Environmental Sciences.
Should you so desire, you and/or your representative may look over any
records, or other evidence held by the local agency before and during the
hearing.
If you have any questions about how the hearing will be run, yd*- may contact
th« State VIC Office at 44^4740, or the hearing official at .
WORKING WITH VENDORS
1. Informing Vendors of WIC Program Availability
2. Vendor Training/Orientation
3. Vendor Contract (Responsibilities Agreement)
4. Monitoring Vendor Compliance
5. Vendor Abuse
6. Food Vendor Qualifications
7. Authorization of Food Vendors
8. High-Risk Vendor Monitoring Summary
<C
X-83
>
1. INFORMING VENDORS OF WIC PROGRAM AVAILABILITY
SAMPLE LETTER FOR VENDORS
(DATE)
(Grocer Address)
Dear Manager (Grocer or Dairy Name) :
The Supplemental Food Program for Women, Infants and Children (WIC) will be
holding a short, informative meeting for all vendors, both grocers and dairi
in our area. At that time information about the WIC Program and vendor responsj
bilitles will be presented, and any questions you might have answered. Vendor
contracts for the coming year will be signed at this meeting.
If you wish to participate in the WIC Program for the coming year, please attend
this meeting. The date, time and location of the meeting is:
lries ,
Attached is a brochure about the WIC Program. Should you have any questions
about it, or about the meeting, please call.
Sincerely,
Each local WIC agency shall offer participation in the Program annual 1y to all
groceries and dairies in their area, prior to renewal of contracts. Check local
telephone books and listings of retailers provided by the State Office, and
contact them by placing a public notice in area newspapers, or by sending each
retailer a form letter, such as the one above.
Keep a file in the local agency office documenting which vendors have been
contacted and how, and their response.
»
X-84
VENDOR TRAINING/ORIENTATION
Local agencies shall provide an orientation/training session annually for
all vendors participating in the WIC Program. Training materials, includ-
ing slides, cassettes, pamphlets, brochures and handouts are available from
the State Office, and should be reviewed before developing such materials
at the local level to avoid duplication.
The meeting should cover the following topics:
a. Brief overview of the WIC Program, including:
(1) Eligibility requirements for clients.
(2) Summary of USDA appropriations, and the counties and reservations
participating in the Program in Montana at the present time.
(3) Explanation of the 3 components of WIC: Food, health care and
nutrition education.
b. Explanation of the WIC food package -- the difference between WIC and
Food Stamp Program.
c. Vendor Responsibilities, as delineated in the WIC VENDOR AGREEMENT.
d. Sanctions against vendors for vendor abuse, fair hearing procedures.
e. New policies or procedures.
f. Procedures for addition and/or removal of acceptable WIC foods on
approved food lists. All such additions or deletions must have State
approval .
g. Evaluation of presentation.
h. Handouts of brochures, pamphlets, authorized food and grocer price
list, Policies and Procedures Manual, Food Choices, etc.
i. State monitoring procedures.
CONTRACTS MAY BE SIGNED AT THIS MEETING.
X-85
VENDOR CONTRACT/AGREEMENT
A standardized WIC Vendor Agreement will be provided by the State Agency
for distribution to local agencies. Local agency staff must go over this
agreement, item by item, with each vendor participating in the Program to
ensure their understanding of the requirements and possible penalties for
not meeting those requirements.
Vendors will be given approved food lists along with their signed agree-
ments.
All completed contracts will be sent to the State Office.
I
X-86
•
Instructions for Completing WIC Vendor Agreement
A. Renewal of Vendor Agreements
Renew all vendor agreements using our revised format whenever current
agreements expire. New federal regulations mandate the inclusion of
additional vendor requirements not covered in previous contracts.
This new agreement should clarify vendor responsibilities and encour-
age program compliance.
B. Vendor Data Form
In order to get the best results within the vendor reporting system,
it is important that clinics input accurate information. The follow-
ing instructions will assist you in correctly completing the vendor
form for two situations described below:
Situation I:
If a data form was previously submitted for a vendor, please fill
in the following information to update page 4 of subsequent
vendor agreements.
Clinic Number: Enter the first 3 digits listed on your
vouchers.
Vendor Name: Enter the two digit number assigned by the
State Agency.
Date of Agreement: List the new date the agreement was
signed: Month, Day, Year.
Termination Date of Agreement: List the new expiration date
— usually the same month and day the following year.
Update Code: Enter "C" for changing or updating information
for your vendor agreement.
Vendor Monitoring Date: Enter the date of your last review
only if it has changed from your previous submission.
Do not fill in other information blocks unless data, specific to
that block, has changed from your previous submission. This
action will prevent duplication of currently correct data by key
punch entry.
Please double check your information for accuracy and send the
original (white) copy of page 4 to the State Agency within 15
days after completion. Retain the yellow copy in your vendor
file. Give your vendor a copy of the agreement along with the
pink copy of page 4.
Use a pen to print capital letters and numbers. Leave a blank (H
space between words. Record a zero in the preceding space when
X-87
indicating single digit figures for dates. A sample form is
completed for your review.
We encourage you to complete your vendor monitoring requirements
at the same time you renew the vendor agreement.
Situation II:
If you are completing an initial submission of a vendor data form
(first time only), please fill in the following information:
MIC Clinic Name: Record your program's title. Leave a
blank space between words.
Name of Firm: Enter the full name of the business - use the
vendor's mailing title.
Street Address : Enter mailing address.
Town: List only the town's name, not the state.
■Zip: Record Zip Code for mailing.
Phone: Enter the vendor's phone number - put a hyphen in
the 4th space.
Grocery Store Manager or Dairy Representative: Record the
manager's name. This should be the same person who signed
the agreement.
Date of Agreement: List the date the agreement was signed;
Month, Day, Year.
Termination Date of Agreement: List the date the agreement
will expire - usually the same month and day the following
year.
Clinic Number: Enter the first 3 digits listed on your
vouchers.
Vendor Number: Leave blank for the first submission. The
State Agency will assign vendor numbers.
Update Code: Leave blank for the first submission. Enter
code letters for subsequent updated information.
Type Code: Enter the corresponding code which best de-
scribes your vendor.
Vendor Monitoring Date: Update vendor monitoring date if it
has changed from your previous submission.
X-88
Do not fill in the Vendor Number or Update Code during the first
submission of a vendor form. This information will be assigned
by the State Agency.
The State Agency will send you a revised list of vendor numbers within
30 days after receipt of vendor forms. Specific dates will be provid-
ed for including vendor numbers in your log sheet data. You may
request mailing labels for each vendor if desired.
9
i
X-89
SITUATION I
)
WIC" ( 'link Same
lie ill hirtu
lt
/'p
Phone
(.roccn Mori- Manager or Dam Representative
Street Vildros
— l n: 3
I IIW
1
1
1
■
( linn* Number
215-
/
Vendor N
ninl
O £T
l.pd
ale (
ndi-
llljllk = J.I.I
< = rlmnur
l> = ilrlrii-
T»pi' Ciidc
□
l> = I>jim M = Mil in & P«|i
C = Convenience O = Other
S = Supermarket \\ = YVhulrtalc
IhK agreement stall lake eflecl on
and \hjll terminate on
o
/
o
/
0
§ 3
O (a I 0 % ¥
Vendor
Monitoring
Date
0 C~ I \o % 3
Munlh l)jy Year
(.For State WIC
siaius Cudc 1 1
Itrniinjiiun
office use
only)
Dale 1
Month
Day \iar
*
SITUATION II
Siren -Vrfdrevi
1 0 O o B\o\U LDER
a vie
limn
h\e l\e n a
Zip
Phone
^9 fc|o /
H2-353^
(•r*Ker> Store Manager or l)air> Representative
J O U W GROCER
1 hi\ agreement shall taUe cffccl on
and shall terminate on
0 6 / S $ 3
0 <r I 8 % H
Vendor
Mcnitoring_
Date
W It' Clinic Name
Do \R. I TEl
IW I C P R 0 ^JR A M
Name ol Kirm
IB UTT R\EY
food IsItIoIr e
Clinic Number
315
Vendor Nuinlief
Ipdalc (ode
D
Blank = j.i.I
C = I'buncr
I) = dell-It
Type Cudc
I) = Dairy M = Mum a I'up
t" = C<mvrnkrncc <> = Other
s = Supermarket \\ = Wholesale
0 6|/|g|g|3
Month Day Year
o
(.For State WIC
Status Code 1 1
Termination
office use
only)
Dale 1 1 1
Munlh
Da\ Yes
ir
White - State
Yellow - Local Agency
X-90
MONTANA WIC PROGRAM VENDOR AGREEMENT
VENDOR NAME:
The LOCAL AGENCY has entered into an AGREEMENT with the Montana Department of Health
and Environmental Sciences (referred to as DEPARTMENT) to participate in the Special
Supplemental Food Program for Women, Infants and Children (referred to as WIC),
conducted by the United States Department of Agriculture under regulations published
in 7 CFR Part 246 (referred to as REGULATIONS).
The DEPARTMENT, acting through the LOCAL AGENCY, hereby enters into an AGREEMENT with
the above named retail food outlet (referred to as VENDOR) for the purpose of provid-
ing supplemental foods to eligible persons participating in the WIC Program. This
AGREEMENT shall become final upon signature by the VENDOR and the LOCAL AGENCY which
is acting on behalf of the DEPARTMENT.
I . Duration
A. This AGREEMENT is valid for a period of one year from date of signature.
II . The VENDOR agrees to perform the following responsibilities:
A. Stock sufficient guantities of the following food items:
(Strike out the following food item? which do not apply to dairies or
pharmacies . )
1) Iron-fortified infant -formula;
?-) Pasteurized f 1 uid cow's milk (whole, lowfat and skim);
3) Nonfat or lowfat dry milk;
4) Canned evaporated cow's milk;
5) Four or more kinds of natural cheese;
6) Orange and grapefruit and apple juice that contains a minimum of 30
milligrams of Vitamin C per 100 milliliters (the label will say 6
ounce serving supplies 100 percent of USRDA for Vitamin C);
7) Four or more kinds of hot or cold cereals that contain at least 45
percent USRDA for iron or 28 milligrams of iror per 100 grams of dry
cereal and not more than ?1.2 grams of sucrose and other sugars per
100 grams of dry cereal (6 grams per ounce);
8) Iron-fortified infant dry cereal which contains a minimum of 45
milligrams of iron per 100 qrams of dry cereal;
9) Large Grade AA eaos and 3 or more kinds of dry beans or peas;
10) Formula authorized by the DEPARTMENT.
B. Provide supplemental foods to WIC participants only upon receipt of a
properly completed food voucher and tc complete the food voucher trans-
action properly:
1) To accept vouchers issued by the LOCAL AGENCY only for authorized food
items, unless there is an authorized substitution shown on the
"Authorized Food and Price List" card. Rainchecks may be given only
if no authorized food substitutions are available.
♦
X-91
2) To refuse to alter vouchers or to accept a1! vouchers showing un-
authorized alterations.
3) To refuse to accept vouchers more than 30 days after the date of
issuance.
4) To refuse to accept a voucher from anyone other than the designated
recipient, unless a handwritten note, signed by the WIC recipient or
guardian, accompanies the voucher.
5) To reouire the WIC recipient tn countersign the voucher after the
products are totaled and to assure that, signatures are identical. If
(4) above applies, assure that the signatures on the voucher and the
note are identical .
6) To enter the amount o* the purchase in the "pay exactly" block on the
voucher. The VENDOR shall provit'<a supplemental foods at. the current
price (time of purchase) or at less than the current price charged to
other customers. The VENDCP shall not give change or extra groceries
to the participant if the actual price is less than the estimated
price. Personal payment cannot be requested -from WIC recipients for
foods listed on the WIC voucher. Vouchers cannot be accepted for
credit on past accounts.
7) To submit vouchers for payment to the bank within 60 days of the
issuance date. Vouchers redeemed 60 days after' the issuance date may
be rejected ?or payment by the DEPARTMENT.
8) To not cash food vouchers over the "maximum value" written on the
voucher. The DEPARTMENT will reject vouchers cashed over the "maximum
value" and return them through the banking system.
9) To not seek restitution from participants for food instruments not
paid by the DEPARTMENT.
C. The DEPARTMENT may deny payment to VENDORS for incorrect redemption of
vouchers or may demand refunds for improper payments already made. The
VENDOR shall not allow the actual purchase price to exceed the estimated
purchase price as it appears on the voucher by more +han 10%. In cases
where the overcharge does exceed 10% of the estimated price or improper
redemptions are suspected, the VENDOR will refund the difference between
the estimated price and the amount charged, unless the VENDOR can prove
there is no overcharge or improper redemption. The estimated purchase
price (obtained from vendor price lists) will be used when past food prices
cannot be substantiated, or if shelf price records are unavailable for the
time period when the draft was issued.
D. To provide access to WIC Program reviewers to food instruments negotiated
during the day of review, at the request of the reviewer, plus shelf price
records, if available. Annual on-site reviews by LOCAL AGENCY staff of all
VEND0PS accepting WIC food vouchers will be made for the purpose of observ-
ing VENDOR compliance.
X-92
E. To complete and return the WIC Authorized Food and Price List to the local
WIC agency once every three (3) months or more often if requested.
Ill . Program Abuse and Sanctions
A. Vendor abuse is defined as failure to comply with any part of a current
signed WIC Vendor AGREEMENT. These include, but are not limited to,
providing cash, unauthorized foods or other items to participants in lieu
of authorized supplemental foods; charging the DEPARTMENT for foods not
received by the participant; and charging the DEPARTMENT more for supple-
mental foods than other customers are charged for the same food item.
B. If abuse has come about through misunderstanding or the part of the VENDOR,
then an on-site visit by LOCAL AGENCY staff will be conducted to rectify
the problem. However, if deliberate fraud apoears to be the motive for
abuse, or if the problem persists after the staff visit, the VENDOR will be
sent a letter detailing the problem, requesting comDliance with the current
AGREEMENT, and allowing thirty (30) calendar days for corrective action.
If the VENDOR is not in compliance within thirty (30) calendar days as
evidenced by a return on-site visit, the DEPARTMENT will immediately
institute the following sanctions depending on the severity of the vio-
lation.
C. Upon notification by the LOCAL AGENCY, and after Part B ( above) is accom-
plished, the following sanctions and penalties shall be applied.
1. Upon a final decision to apply sanctions, the execution of the pen-
alties shall take place.
a. Penaltv I - Warninq Letter
Violations:
(1) Use of WIC food vouchers by someone other than the person
whose name appears on the voucher un^ss a proxie is des-
ignated by signed consent of the participant.
(2) VENDOR redeems vouchers for non-authorized food items within
WIC food categories.
(3) VENDOR is temporarily out of stock of WIC foods.
b. Penalty II - Six Months Disqualification
(1) Violation of above a^ter warning.
'■?.) VENDOR charges WIC participants more than others.
(3) VENDOR charges participants additional cash to use vouchers.
(4) Treats participants in a discourteous manner.
(5) Sells food items not in WIC food categories.
4
X-93
c. Penalty III - Qnp Year Disqualification
(1^ VENDOR overcharges State for products sold exceeding $250 in
one contract year.
f2) Sale of non-food items including alcohol or tobacco.
(3) VENDOR refuses to stock WIC -foods but continues to accept
vouchers .
(4) VEwD0R exchanges vouchees for cash or credit in an amount
less than S100.00.
(5) Fraudulent claim that an item was disbursed when in fact no
disbursement took place.
(6) The acceptance of WIT vouchers in payment of credit
accounts.
d. Penalty IV - Two Years Disqualification
(1) VENDOR continues to violate Program while swaiting appeal
hearing.
e. Penalty V - Threp Years Disqualification
(1) VENDOR exchanoes vouchers for cash or credit in excess o^
$100.00.
(2) VENDOR discounts voucher or has a discounting pricing
system.
(3) VENDOR violates Program guidelines after re-entry into
Program following a disoual ification.
D. ALL SANCTIONS CAN PE APPEALED THROUGH THE FAIR HEARING PROCESS.
E. The DEPARTMENT reserves the right to take thp VENDOR'S history and an
circumstances into consideration before apDlyina sanctions or disoual ifica-
tion of a VENDOR.
F. A VENDOR who commits fraud or abuse of the WJC Program is liable to prose-
cution under applicable Federal, State or local laws. Under §246.23 o^ the
REGULATIONS, those who have willfully misapplied, stolen or fraudulently
obtained WIC funds shall be subject to a fine of not more than $10,000 or
imprisonment for not more than five (5) years or both, if the value of the
funds is $10D or more. If the value is 1ess than $100, then the penalties
are a fine of not more than 1,000 or imprisonment for not more than one (1)
•'ear or both.
X-94
IV. General Conditions '
A. Pursuant to 49-2-303 and 49-3-207 of the Montana Code Annotated, the VENDOR
agrees to perform no part of this AGREEMENT in a manner which discriminates
against any person on the basis of race, color, religious creed, political
ideas, sex, age, marital status, physical or mental handicap, national
origin or ancestry. In addition, VENDORS must be in compliance with
provisions of regulations 7 CFR, Parts 15, 15a, and 15b.
B. Neither the VENDOR nor the DEPARTMENT has an obligation to renew the
AGREEMENT. Either party may terminate this AGREEMENT for reason of Program
abuse and/or failure to perform any of the duties or conditions contained
in this AGREEMENT after giving thirty (30) days written notice. If the
VENDOR is denied participation or disqualified, the VENDOR will receive, in
writing, thirty (30) days notice of suspension from the WIC Program. The
VENDOR has the right to appeal that decision if notice is given in writing
to the LOCAL AGENCY within fifteen (15) days after suspension. All VENDOR
sanctions can be appealed through the fair hearing procesr,. Expiration of
this AGREEMENT is not subject to appeal.
C. A VENDOR who is currently disqualified from another Food and Nutrition
Service Program (e.g., Food Stamps) may be disqualified from the WIC
Program. Food Stamp disqualifications over 180 days may be disqualified
from the WIC Program from the date the DEPARTMENT is notified until the
Food Stamp Program reinstates the VENDOR.
D. The store manager or authorized representative, such as ^he head cashier, ^
shall attend training workshops and accept training on WIC procedures. The
VENDOR shall inform and train cashiers or other staff on Program require-
ments. The VENDOR shall be accountable for actions of employees in the
utilization of food instruments or provision of supplemental foods.
E. The same courtesy and service shall be shown toward WIC recipients as
offered to other customers.
F. The VENDOR shall notify the LOCAL AGENCY when the VENDOR ceases operation
cr ownership changes. The AGREEMENT is null and void if the ownership
changes.
G. The VENDOR shall inform the DEPARTMENT of any potential conflict of inter-
est between the local WIC staff and VENDOR personnel.
V. EXECUTION
This AGREEMENT consists of F pages and one attachment (Vendor Data Form). The
VENDOR will receive a copy of this AGREEMENT which has the same force and effect
for all purposes as the original.
To express the parties' intent to be bound by the terms of this AGREEMENT, they
will execute this document by signing and dating the designated spaces provided
at the bottom of the attachment (Vendor Data Form).
DT/dw/llc <
X-95
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS AND CHILDREN (VVIC)
MONTANA VENDOR DATA FORM
DATE:
VENDOR NAME:
VENDOR NUMBER:
PROGRAM NAME:
CLINIC NUMBER:
Whenever vendor agreements are signed, each local agency is responsible for updating the vendor information using the form
below.
If vendor monitoring is done the same time vendor agreements are updated, the new monitoring date can be added to this Vendor
Data Form.
If a vendor data form was previously submitted for this vendor, enter the clinic number, vendor number, update code (in this case
it is always C), and the new agreement dates. Other information blocks may be filled in if data specific to that block has changed
from the last submission of a data form.
If you are completing an initial submission of a vendor data form for a new vendor (first time only), please fill in all the informa-
tion blocks except vendor number, update code, and vendor monitoring date. Vendor numbers will be assigned by the State
Agency. Send the white copy to the State Agency within 15 days after completion.
Clinic Number
Street
Address
Town
Zip
Grocer} Siore Manager r
r Dam Representative
VMC Clinic
Same
Name of Firm
D = Dairy
C = Convenience
S = Supermarket
Vendor Number
Lpdale Code
□
Blank = add
C = change
D - delete
T»pe Code
□
M = Mom &. Pop
O = Other
W = Wholesale
This agreement •.hall take effect on
and shall terminate on
Vendor
Monitoring
Date
Month Da)
(For Slate WIC office use only)
Sinus Code | )
Termination
Dale |
Month [
la>
Year
(Signature of Local Agency WIC Project Director)
(Date Signed)
(Signature of Manager/Owner)
(Date Signed)
WIC BENEFITS ARE AVAILABLE TO ALL PERSONS REGARDLESS OF RACE, COLOR, NATIONAL ORIGIN, AGE,
SEX OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, WRITE IMMEDIATELY TO
THE SECRETARY OF AGRICULTURE OR DIRECTOR, OFFICE OF ADVOCACY AND ENTERPRISE, USDA, WASH-
INGTON, D.C. 20250.
While — Slate
Yellow — Local Agency
Pink — Vendor
Revised 2 86
X-96
MONITORING VENDOR COMPLIANCE
Local and/or State WIC staff will perform an annual on-site review of all
vendors for conformance to the WIC Vendor Agreement, unless exceptions are
approved in accordance with 7 CFR 246.10 d (5).
a. Local agency staff should request the following reports prior to
planned monitoring visits (see page VIII-9 for instructions):
V04- Drafts Paid Exactly Equal Issued (WA634RCV).
V03- Drafts Redeemed for Exact Dollar Amount (WA634RCV).
V02- Paid Amount Exceeds Estimated Amount by 20% or More.
V01- Paid Amount is Below Estimate by 10% or more.
Vendor Draft Activity Report (WA633R1).
b. Any vendor who fits into any one of the following categories is
considered high-risk and must receive a priority for on-site
monitoring:
1) Collections on exceptions greater than $15.00 per year;
2) High incidence of drafts redeemed for exact dollar amounts; ^
3) High incidence of drafts where the paid amount exactly equals
issued amount;
4) Issued value exceeds $3,000 per month;
5) Disqualification or civil money penalty from Food Stamps within
the last three years;
6) Other (e.g., participant complaints, a history of problems).
c. Each on-site review should consist of three steps:
Step One: Prior to review, examine all vendor reports, files, client
complaints, etc.
Step Two: At the store, complete the Vendor Monitoring Report (see
page VIII-15).
Step Three: Evaluate your findings with one of the following results:
1) Everything OK, no further action needed. Leave a copy of review
with the store.
2) Some program differences, follow-up letter to vendor with copy to
State Agency. Record the vendor's corrective action plans under
item #16 on the Vendor Monitoring Report.
X-97
3) Many program problems; notify State Agency immediately for
further guidance.
IF LEGAL ACTION IS NECESSARY TO RESOLVE PROBLEMS, THE STATE OFFICE WILL BE
RESPONSIBLE FOR NOTIFYING VENDOR OF SUCH ACTION AND FOLLOWING THROUGH.
X-98
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X-99
5. VENDOR ABUSE
a. Vendor abuse is defined as failure to comply with any part of a
current signed WIC Vendor Agreement. These include, but are not
limited to, providing cash, unauthorized foods or other items to
participants in lieu of authorized supplemental foods; charging the
State or local agency for foods not received by the participant; and
charging the State or local agency more for supplemental foods than
other customers are charged for the same food item.
b. Local Agency Responsibilities:
(1) Gather all pertinent information possible. Try to get the
complainant's name and address, but avoid scare tactics and
protect confidentiality.
(2) Ascertain, if possible, whether the abuse is deliberate or has
come about through misunderstanding on the part of the vendor.
If the latter, an on-site visit by local agency staff may rectify
the problem.
(3) If fraud appears to be the motive for abuse, or if the problem
persists after the staff visit, vendor will be sent a letter
detailing the problem, requesting compliance with the current
agreement, and allowing thirty calendar days for currective
action. The letter shall be sent via registered mail, return
receipt requested.
(4) If the vendor is not in compliance within thirty (30) calendar
days as evidenced by a return on-site visit, notify the State
Agency immediately.
c. State Agency Responsibilities:
When abuse is reported by a local agency, and after (1-4) above have
been accomplished:
(1) Upon notification by the local agency, the following shall be
applied:
a. Penalty I - Warning Letter
Violations:
(1) Use of WIC food vouchers by someone other than the
person whose name appears on the voucher unless a
proxie is designated by signed consent of the partici-
pant.
(2) Failure to comply with any other contractual obligation
not otherwise listed.
(3) Vendor redeems vouchers for non-authorized food items
within WIC food categories.
X-100
(4) Vendor is temporarily out of stock.
(5) Forcing participant to purchase specific brand names
when a variety of brands are authorized and stocked.
b. Penalty II - Six Months Termination
(1) Violation of above after warning.
(2) Vendor charges WIC participants more than others.
(3) Vendor charges participants additional cash to use
vouchers.
(4) Treats participants in a discourteous manner.
(5) Sells food items not in WIC food categories.
c. Penalty III - One Year Termination
(1) Vendor overcharges State for products sold exceeding
$250.00 in one' vendor contract year.
(2) Sale of non-food items including alcohol or tobacco.
(3) Vendor refuses to stock WIC foods but continues to (
accept vouchers. ■•
(4) Vendor exchanges vouchers for cash or credit in an
amount less than $100.00.
(5) Fraudulent claim that an item was disbursed when in
fact no disbursement took place.
(6) The acceptance of WIC vouchers in payment of credit
accounts.
d. Penalty IV - Two Years Termination
(1) Vendor continues to violate Program while awaiting
appeal hearing.
e. Penalty V - Three Years Termination
(1) Vendor exchanges vouchers for cash or credit in excess
of $100.00.
(2) Vendor discounts voucher or has a discounting pricing
system.
(3) Vendor violates Program guidelines after re-entry into
Program following a disqualification.
-
X-101
f. FOOD STAMP DISQUALIFICATIONS OVER 180 DAYS MAY BE DISQUAL-
IFIED FROM THE WIC PROGRAM FROM THE DATE THE STATE IS
NOTIFIED UNTIL THE FOOD STAMP PROGRAM REINSTATES THE VENDOR.
g. ALL SANCTIONS CAN BE APPEALED THROUGH THE FAIR HEARING
PROCESS.
Vendor Termination Procedures:
Upon a decision to terminate, the following activities shall take
place:
(1) A central file shall be established at the State Agency to
contain all information necessary to back up the termination as
well as material relatea to the termination itself.
.(2) Upon a decision to terminate, a letter will go out from the State
Agency to the venaor notifying the vendor of the termination.
Terminations shall take effect 30 days from the date of the
letter. Each vendor shall have 15 days from receipt of the
letter to appeal the decision.
(3) Copies of all letters of termination shall go to the WIC Regional
Office, the local agency and USDA. A copy shall go to each local
agency who has this vendor in its listing in order to notify the
agency that some action is being taken on the vendor.
(4) If the vendor does not appeal, termination shall take effect on
the date as indicated, and agencies shall discontinue issuance of
vouchers to the vendor.
(5) Terminated vendors shall be deleted from agency lists.
(6) If the vendor appeals, all adverse action shall be withheld until
an appeal decision is reached. A letter shall go out to the
vendor acknowledging the appeal and delaying action on the
termination until a decision is reached.
(7) If a vendor loses an appeal, the termination shall take place 30
days from the date of decision.
(8) Upon the final decision to terminate, the State Agency shall
contact the local agency to return vouchers made out to the
vendor.
(9) State Agency files will be closed for suspended vendors until the
period of termination ends, at which time information may be
reviewed for consideration of the vendor reappl ication if submit-
ted.
X-102
e. Reduction of Sanctions:
When the State receives an appeal from a vendor asking for a reduction
of the sanction imposed upon him, the State may reduce the sanction
under the following conditions:
(1) The vendor is the only WIC vendor in the geographic area, and
suspension of the vendor would cause undue hardship en the
participants in the area.
(2) The owner of the market has owned the market for less than 6
months, has no history of prior FNS food program violations, and
the violation appears to be the result of a clear lack of under-
standing of the rules.
(3) The only major violation was overcharge, and the total amount of
the overcharge can be determined.
(4) It is clearly in the best interest of the State to allow the
vendor to repay monies obtained in violation of Federal Regu-
lations and State Guidelines AND the vendor would be in danger of
losing his business if the suspension were carried out.
When the State elects to reduce a suspension, the vendor shall be made
to serve at least a 3-month suspension as well as return any money
that was requested. The one exception is when the vendor is the only &
vendor in the geographic area, in which case the vendor may have his
suspension eliminated and be made to pay an amount above the money to
be reclaimed.
f . Vendor Payback:
In some cases it may be to the advantage of the State to allow the
terminated vendor to pay back any overcharge determined by the State
and be put on probation. Criteria used in making this decision should
include:
(1) The vendor's record of past violations.
(2) The length of time the vendor has owned the store.
(3) Adverse impact on participants if the vendor is terminated.
(4) Number of alternative stores in the area.
If a decision to allow payback in lieu of termination is made, the
State shall determine the amount of overcharge using the best avail-
able data. The amount of overcharge shall be collected in the form of
a check or money order, and made payable to the Department of Health
and Environmental Sciences. In cases of large dollar amounts, the
State may set up a time payment system to allow the vendor a chance to
pay without creating an excessive business loss.
X-103
6. FOOD VENDOR QUALIFICATIONS
a. Food vendor qualifications are:
(1) Stocks and maintains appropriate quantities of authorized WIC
foods;
(2) Accessible to WIC clients;
(3) Has not been disqualified from the Food Stamp Program;
(4) Is currently licensed by appropriate State of Montana agencies.
b. Review of vendor qualifications will consist of:
(1) Review annually all local agency vendor monitoring reports;
(2) On-site visits during regularly scheduled local agency monitoring
visits;
(3) Shared information through cooperation with the Montana Food
Stamp Off icer-in-Charge;
(4) File reviews of one-half the total currently authorized vendors
every year; and
(5) On-site follow-up to items (1) and (4) when warranted by incom-
plete information or complaint.
c. Under special circumstances, the State Agency may delegate such review
authority to local agency staff.
7. AUTHORIZATION OF FOOD VENDORS
a. Any food vendor participating in the Montana WIC Program prior to May
23, 1983, is hereby authorized to continue participation in the WIC
Program. No further action by either the vendor or local agency is
necessary.
b. There is no limit at this time to the number of vendors who may
participate in the WIC Program.
c. New (not currently participating, or not participating prior to May
23, 1983) vendors shall have a documented on-site visit prior to, or
at the time of initial authorization, by the local WIC agency. A
signed Vendor Application in addition to a signed vendor agreement
shall constitute such documentation.
d. All food vendors within the State of Montana are recognized by the
State Agency to be eligible to participate in WIC, subject to Program
Regulations and requirements.
e. The following criteria must be evaluated for initial authorization of
new vendors ("new" is defined in #3 above):
X-104
«
(1) Maintenance of adequate variety and stock of all categories of
approved WIC foods;
(2) Accessibility to WIC participants;
(3) History of compliance with Food Stamp Program;
(4) Store Sanitation as evidenced by store license.
8. HIGH-RISK VENDOR MONITORING SUMMARY
a. A summary of the results of the monitoring of high risk and represen-
tative food vendors and the review of food instruments will be submit-
ted annually to the Food and Nutrition Service (FNS) by the State
Agency within four (4) months after the end of each fiscal year on
forms supplied by FNS.
9. COMPLAINTS
a. Anyone alleging discrimination on the basis of race, color, national
origin, age, sex, or handicap has the right to file a complaint. All
complaints written or verbal shall be accepted and forwarded immedi-
ately to the Secretary of Agriculture or Director, Office of Advocacy
and Enterprise, USDA, Washington, D.C. 20250, with a copy to the
MPRO.
b. Participant complaints about a vendor:
(1) A vendor violation that is verified only by WIC participant
complaints requires corroboration by three separate WIC partici-
pants of the same abuse by the same vendor. That is, three
complaints are necessary for one instance of documented abuse.
(2) These complaints must be written (or dictated) by the WIC partic-
ipant. The language used in the complaint must be the actual
words of the WIC participant; a summation or notation by a WIC
staff member is not sufficient documentation.
(3) The WIC participant may choose to leave the complaints unsigned.
The local program director (or designated staff member) must
certify the receipt of the complaint and indicate the time and
date it is recorded. This certification will attest to the fact
that the complaint was received by a current WIC participant and
was given freely and in good faith.
c. Vendor complaints about WIC are handled as described on Page XI 1-2 .
X-105
Supplemental Food Program for Women, Infants and Children (WIC)
Montana UIC Program
Vendor Application
1. Vendor Name
(Hereinafter referred to as "Vendor")
2. Vendor Address
3. Vendor Telephone
4. Name of Owner (If different than #1)
5. Name of Manager
6. Federal Employer Tax I.D. #
7. Food Stamp Vendor No.
(If Applicable)
II. Vendor hereby applies for authorization to participate in the HIC Program.
Vendor has received the WIC Vendor Packet which includes: Sample vouch-
ers, Window poster, Price report sheet, and required procedures.
Vendor has read and understands the provisions in the Vendor Agreement.
Vendor represents that it and its employees will comply with the WIC
Program regulations, and understands that any authorization to participate
may be revoked for any violation of the regulations by it or its employ-
ees.
Vendor understands that false information contained herein may result in
withdrawal of approval to participate in the WIC Program.
The undersigned represents that he/she is either the sole proprietor of
the vendor or that he/she has authority to contract for and in behalf of
the vendor.
III. Vendor qualifications for participation in the WIC Program are:
A. Stocks and maintains appropriate quantities of authorized WIC foods:
Cow's milk - fluid, fresh (whole, lowfat and skim);
Canned evaporated cow's milk;
Instant dry cow milk;
Iron-fortified infant formulas;
Soy base infant formula;
Four or more kinds of cheeses;
Four or more kinds of orange and/or grapefruit and/or other juices
that contain 30 mg. of Vitamin C per 100 milliliters (the _
nutrient label will say one 6 oz. serving of full strength juice
meets 100% of the U.S.R.D.A. for Vitamin C for adults);
X-106
Four or more kinds of hot or cold cereal that meets at least 45% of
the U.S.R.D.A. for iron or 28 mg. of iron per 100 grams dry
portion and not more than 21.2 grams of sucrose and other sugars
per 100 grams of dry cereal (6 grams/ounce);
Iron fortified infant dry cereal which contains a minimum of 45
milligrams of iron per 100 grams of dry cereal;
Large Grade AA eggs;
Three or more kinds of mature dry beans or peas;
And/or special formula which is authorized by the Montana State
Department of Health and Environmental Sciences.
B. Is accessible to WIC clients;
C. Has not been disqualified from the Food Stamp Program; and
D. Is currently licensed by appropriate State of Montana agencies.
Vendor or Authorized Agent Date
has verified the above information
Name or Local Agency
during an on-site visit to vendor on
Date
Signature of Authorized WIC Agency Director
DT/war-Sl
4
X-107
FINANCIAL MANAGEMENl
I. ALLOWABLE EXPENDITURES
II. BUDGET GUIDELINES
A. Annual Budget Request
B. Requests for Program Changes
III. MONTHLY REPORTING REQUIREMENTS
A. Expenditure Report and Accountability Statement
B. Vendor Invoice
C. Travel Expense Voucher
IV. EQUIPMENT PURCHASE AND INVENTORY
V. BUDGET STATUS
VI. FISCAL YEAR-END CLOSE OUT
VII. NUTRITION EDUCATION EXPENDITURES
X-IOS
FINANCIAL MANAGEMENT
A budget, to determine the amount of funds a local agency will receive frcm the
State WIC Office, is attached to the agreement negotiated between that agency
and the State Department of Health and Environmental Sciences, and becomes a
part of that agreement. The agreement and budget are usually negotiated once a
year.
Prior to the expiration of their current agreement, the State Office sends a
packet of materials to the local agency to assist them in budget preparation.
This packet includes guidelines and instructions, including but not limited to:
a. Deadline date for submission;
b. Nutritional health plan requirements;
c. Request for expansion; and
d. Necessary forms.
•
X-109
ALLOWABLE WIC PROGRAM EXPENDITURES
A. Personnel : Staff shall include a competent professional authority
pursuant to Section II (8) of the Agreement and a WIC Aide.
1. Salaries and benefits are allowable at a rate customary and
reasonable for services rendered specifically for the execution
of the WIC Program contract.
2. Payrolls must be supported by time and attendance or equivalent
records for individual employees.
B. Direct Costs: Must be supported by written documents kept on file
at the local agency, and reported on the Monthly Expenditure Report.
1. Travel : Expenses for approved workshops and program objectives
shall not exceed the amount customarily paid to local agency
staff. Expenses for attendance at the required State Workshop
are allowable as described in Section II, paragraph (B)(2) of
the Agreement.
2. Equipment: Office equipment may be procured locally. Special
purchase of medical equipment is allowable for certification
processes. Purchases of equipment costing more than $200.00
must be approved in writing from the State Office. Purchases
for over $2,500.00 must be approved by the USDA Regional
Office. All items remain the property of the State Agency, and
should be identified by inventory tags, which will be supplied
by the State Agency.
3. Supplies: Includes expenditures for office supplies, dispos-
able clinical supplies, educational supplies and consumable
commodities for demonstration purposes.
4. Contractual : Rent of space or equipment, utilities, telephone,
etc.
5. Certification Procedures: Expenses for laboratory tests and
medical supplies which are used to determine eligibility.
• 6. Other: Nutrition education, outreach services, translators and
interpreters, fair hearings, monitoring, workshop registration
fees, subscriptions, etc. Transportation costs for assuring
clients access to clinics is allowed when prior approval has
been granted by the State Office. Direct reimbursement of
transportation costs to clients is NOT allowable.
X-110
II. BUDGET GUIDELINES
A. Annual Budget Request
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)
BUDGET REQUEST
Montana Department of Health and Environmental Sciences
Agency Name:
Current FY
New FY
Total FTE's (from
attached worksheet)
Budget
Source of Funds
Budget Source of Funds
Personnel
WIC Local Other
WIC Local Other
Salaries
Benefits 5!
Subtotal
Indirect (52 of
Salaries and Benefits)
Operatinq Expenses
Travel
Equipment (greater
than S200
Suppl ies
Rent
Telephone
Postage
Utilities
Nutrition Education
Other (list)
Other (list)
Subtotal
Total Request
8
9
10
11
12
13
14
15
18
19
20
21
22
23
24
25
Prepared by:
DT/war-26b
Date:
26
1. Instructions — Annual Budget Request
a. GENERAL (Lines 1-4 on "Budget Request" form)
Both the "Budget Request" form and the "WIC Personal
Services" form must be filled out. Please write legibly
and be neat. Date and sign the form (Line 28).
Fill in your project name in the upper right-hand corner.
(Line 4) %
X-lll
Agencies with "satellite" programs should submit separate
caseload projections and budget details for each satellite
on separate sheets, with the "Budget Request" form re-
served for the total WIC operation.
Prepare your budget with the assumption that your level of
operation will be the same as the prior year's actual
expenditures. You may include an inflationary increase in
personnel. Do not use an inflation factor in other line
i terns . This will be included by the State Agency at a
later time.
b. CASELOAD (Lines 5-10)
Please indicate, by priority, what caseload you expect to
serve during the next twelve months. Unless you have
specific objectives to reach a certain eligible population
group (approved by the State Agency), use last year's
average monthly caseload.
c. PERSONNEL (lines 12, 15)
Fill out "WIC Personal Services" form and transfer to
"Budget Request" form where indicated.
Whenever possible, consider using volunteers to assist
your office, or sharing arrangements with adjacent
counties.
d. FRINGE BENEFITS (Line 16)
This includes payroll taxes, insurance and other items
specific to your agency. Fill in the percent and dollar
amount.
e. INDIRECT COSTS (Line 18)
Indirect costs are provided at the rate of 5% and are
calculated upon salaries plus benefits. Indirect funds
can be used for accounting, purchasing costs, legal
services, supporting personnel costs, or other WIC-
related operating expenses.
f. TRAVEL (Line 20)
Predict mileage expense to and from satellite sites and
food vendors based upon current rates.
g. EQUIPMENT (Line 21)
Any piece of equipment costing more than $200 must receive
prior written approval from this office (Section I, A (5)
of Agreement). NOTE: Requests for equipment in this
category must be received at least 45 calendar days prior
X-112
to the planned expenditure. Approval of the "Budget ^
Request" form does not constitute approval of equipment;
prior written approval is still needed.
h. SUPPLIES (Line 22)
Self-explanatory,
i. RENT (Line 23)
Self-explanatory,
j. TELEPHONE (Line 24)
Self-explanatory.
k. POSTAGE (Line 25)
Self-explanatory. NOTE: Do not include in any other
category.
1. UTILITIES (Line 26)
Self-explanatory.
m. NUTRITION EDUCATION (Line 27)
Fill out the "Nutrition Education Budget Worksheet" and
transfer to "Budget Request" form where indicated.
n. OTHER (Line 28)
Please identify specifically what this category might
include. Without written detail for this category, any
request for funds in this line item will be denied.
Examples of items to be included under this line item are
laboratory costs (for hematological expenses) or "Con-
tracted Services" for the services of a registered diet-
itian.
X-113
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X-114
B. Requests for Program Changes
Written approval from the State Agency must be granted to a local
agency requesting changes in their WIC Programs in any of the
following areas:
1. Addition of a new site to the program.
2. Expenditures exceeding 10% of the total of any budgeted line
i tern , excluding salaries and benefits .
3. Any monthly expenditures for personnel (salaries and benefits)
exceeding the staffing pattern approved in the current Agree-
ment, indicated in lines 12, 14 and 15 and the "WIC Personnel
Services" form of the budget attachment.
The project director will send a written request to the State Agency
at least 15 days before the desired change is to be made. If the
change is not approved the State Agency has no obligation and will
not reimburse for expenditures incurred by the change.
C. Expansion Into New Areas
The local agency requests an application package from the State
Agency to open a new county project, or expand services to a new
satellite program in another county. Applicant must meet the
criteria set forth on the application form, which is filled out and
sent to the State Office.
Memorandums of cooperation between the governing bodies of the
parent and satellite counties must be included with the application.
The State will judge applications on completeness and fulfillment of
WIC requirements. If the application is denied, or approved but
with no funding available, applicant may resubmit the application at
a later date.
X-115
III. MONTHLY REPORTING REQUIREMENTS
A. Expenditure Report
1. This report is used to justify expenditures paid (obligations
incurred) under the terms of the current Agreement between the
State Agency and the local agency.
2. The form is self-explanatory. All information requested must
be accurately filled in before reimbursement will be approved.
If personnel or other expenditures reported are not complete
for the reporting period, an explanation of this discrepancy
must be attached to the Expenditure Report and be signed by the
Program Director.
3. In the Personnel Breakdown portion, "current month and gross $"
means the total salary paid to WIC employees and billed to the
WIC Program. In the column entitled "Hours Worked" record the
total hours billed to WIC (include holiday and leave hours).
4. In the Financial Accountability portion, year-to-date cash on
hand will always be the first entry at the beginning of a
fiscal year. These "carry- over" funds will be included as
part of the initial advance forwarded to the local agency for
the new Agreement.
5. The Expenditure Report Form is to be completed for each month
and submitted by the 15th of the following month unless an
alternate date has been negotiated. Good cause for an alter-
nate submission date includes, but is not limited to, a differ-
ence between the monthly close-out dates of the WIC Program and
the Agency. (Ref.: Section II, paragraph A(2)(b) of Agree-
ment).
6. NOTE: Incomplete, inaccurate, illegible and unsigned reports
will be returned for correction before being processed at the
State Agency.
7. NOTE: Adjustments included in current monthly Expenditure
Reports should reflect claims not older than those reported on
the previous month's report. Please list the circumstances
which caused the adjustment and the original month in which the
expense occurred.
X-116
MONTANA DEPARTMENT OF HEALTH AND ENVIRONMENTAL SCIENCES
WIC EXPENDITURE REPORT
NAME OF AGENCY
EXPENDITURE
CLASS/CATEGORY
Personnel
Benefits
Indirect Costs
Travel
Equipment
Supplies
Rent
Telephone
PERIOD:
From
19 To
19
CURRENT
CURRENT \ * MONTH +
MONTH + ADJUSTMENTS 'ADJUSTMENTS =
EXPENDITURE
MONTHLY TOTAL
Postage
Utilities
TOTALS
YEAR TO
DATE
EXPENDED
-
wtm-
t-
TOTAL
AMOUNT
BUDGETED
BALANCE
OF
BUDGET
Current Month + Adjustments = Total Billed A xjx-xjx-xjxjxj;
Explanation of Adiustment:
PERSONNEL BREAKDOWN
. 1 1 1 . . u 1 1 1 1 rrrpppy;
NAME
CURRENT
MONTH GROSS S
YEAR TO DATE
GROSS S
TOTAL ►
HOURS WORKED
Monthly Yearly
WIC FINANCIAL
ACCOUNTABILITY STATEMENT
CURRENT MONTH YEAR TO DATE
1 . Cash on Hand
(Balance Irom
previous leportl
2. Funds Received
3 Funds/Cash on
Hand Total . .
4. Total Expend.
5. Cash Balance
after Expend. .
6. Cash Adjustments.
7. Cash on Hand . . $
i Alter Eipendituresi
(End ol June Casn on Hanoi
Explanation of Cash Adjustment:
Program Director Signature
Date Signed
Preparer Signature
HES/WIC 6/80
X-117
Vendor Invoice
To receive funds for your WIC Program from the State Agency, you
must submit a completed Vendor Invoice with your monthly Expenditure
Report.
All invoices must be signed and dated by the project director or
local accounting personnel.
Local agency may request:
1. 1/12 initial drawdown of budgeted funds for new fiscal year, or
new project, less the amount of cash on hand at the end of the
previous year.
2. Reimbursement for monthly expenditures.
STATE OF MONTANA
VENDOR INVOICE
|
• PREPARE IN TRIPLICATE
• SEND ALL COPIES TO VENDOR
• VENDOR RETURNS SIGNED ORIGINAL AND DUPLICATE
RETAINING TRIPLICATE
• FILE ORIGINAL WITH TRANSFER WARRANT CLAIM
VENDOR'S NAME AND ADDRESS
BILLED TO
Dept. of Health & Environmental Sciences
Fiscal Services Bureau
Cogswell Building
Helena, Montana 59620
QUANTITY
DESCRIPTION OF GOODS DELIVERED OR SERVICES RENDERED
AMOUNT
•
* -
GRAND TOTAL ►
o
3
Sj
q:
u
<t
o
Q
*
/ certify that this invoice is correct in ail respects and
that payment has not been received
STATE USE ONLY
APPROVED FOR PAYMENT
Vendor's Name
Date Processed
Autt>ortz*d
Sfgnatun
Vendor's Signature
Omm
Title
X-118
C. Travel
Lodging, per diem and mileage allowances authorized by the Montana
State Legislature will be the maximum rate of reimbursement paid to
WIC personnel by the WIC Program for persons attending and partic-
ipating in continuing education, training or other conferences for
WIC business. These rates are as follows:
Per Diem Rates after October 1, 1983
In-State
Meals Lodging
Breakfast $ 3.00 with receipt $24.00
Midday 3.50 without receipt 7.00
Evening 8.00
Out of State
Breakfast 6.50 with receipt $50.00
Midday 6.50 without receipt 7.00
Evening 12.00
Actual cost cities for lodging are:
Chicago Dallas San Diego Denver
Houston New Haven Minneapolis Boston
San Jose New York Detroit Atlantic City
San Francisco Los Angeles Anchorage Washington, D.C.
Newark
The "actual cost" area is defined as the area contained in the city
limits plus the area within 15 miles of the city limits. The area
immediately surrounding the city's airport would also be included if
it is not within the areas described above.
Current Mileage Rates:
Employees based outside Helena:
$.21/mile for first 1,000 miles driven each month.
$.18/mile for every mile driven over 1,000 per month.
All out of state travel planned by WIC personnel must receive prior
approval by the State Agency. An agenda of workshop or training
activities must be reviewed hy Statp staff to determine if workshop
topics directly relate to WIC functions.
-
X-119
IV. EQUIPMENT PURCHASE AND INVENTORY
Purpose: To establish a uniform purchase and inventory system for allowable WIC
equipment.
A. Purchasing Criteria
1. Instructions: Whenever equipment is purchased for $200.00 or
more, the following guidelines are to be followed:
a. Individual equipment purchases costing $200.00 or more
utilizing WIC funds must receive prior approval in writing
from the State Office.
b. Individual purchases for over $2,500.00 must be approved
by the USDA Regional Office through the State.
c. Special purchases of medical equipment by local agencies
is allowed for certification purposes if prior approval is
received from the State.
d. If approval is given and equipment is purchased, it
becomes the property of the State WIC Program.
B. Equipment Inventory Criteria - Purchases for $200.00 or More
1. Instructions: Whenever equipment is purchased, the following
guidelines will be followed:
a. Fill out the State Purchase Memo form which includes name
of item, serial number, purchased from, date purchased,
and cost. Attach this memo to the back of the Expenditure
Report for the month of purchase. This is a requirement
for inventory purposes. Do not submit a Purchase Memo
form for equipment costing less than $200.00.
b. When the State Office receives the memo, an inventory
number will be issued for the equipment, which will be
sent to the local agency to be attached to the equipment.
c. Items must be identified by a DHES inventory tag displayed
in a conspicuous place.
X-120
CC L *l$ffiu€>T&7l£*t35f& • AND environmental sciences
TO : Project Number DATE:
FROM : State WIC Staff
SUBJECT : Equipment Purchased
Name of Item
Serial Number
Purchased From
Date Purchased
Cost
Attach to expenditure report for month of purchase. This is a
requirement for inventory purchases. When we receive the memo,
you will in turn receive a number to attach to your equipment.
_
d. The State Inventory Worksheet must be logged whenever new
equipment is purchased. An updated copy of this worksheet
must be sent to the State Office during the last week of
December each year for audit purposes^ List equipment
with acquisition costs of $200.00 or more. Do not list
equipment costing less than $200.00.
e. In the event the project ceases its "local agency" rela-
tionship with DHES, all equipment and supplies must be
returned to DHES.
f. Notify State Agency personnel whenever equipment becomes
obsolete or worn out. The State will make arrangements
for purchase of new equipment if necessary.
t
X-121
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Acquisition
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-
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New
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(N or U)
State
Inventory
Number
Location
(List Town)
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BUDGET STATUS
A. Estimating Your Budget Status
1. Contract Requirements
Local agencies will be reimbursed only for personnel approved
in the contract and at a monthly rate no more than l/12th
(8.3%) of the funds allocated for personnel. Line items for
operating expenses (travel, supplies, etc.) can be overspent by
10% only if some other area is underspent to make up the
difference. All information requested on the expenditure
report must be filled in before reimbursement is made. This
includes personnel hours, year- to-date expended, balance of
budget, etc. Because funding for the WIC Program is very tight
nationwide, and because there have been no increases in the
Program, staying within the authorized budget is critical. Any
overspending of WIC budgets will have to be made up from other
funds.
2. How to Estimate
The easiest way to estimate your budget status is to compare
your spending rate for each category (line item) to the recom-
mended spending rate found on the attached chart. As you
figure out whether or not your spending rate is "in line," you
can make necessary adjustments to it. This ongoing budget
analysis will help prevent the overspending of your WIC budget.
Computing Your Spending Rate
At the end of each month:
Add together by line item:
(1) expenditures -- what has been paid for services or goods
already received? Money spent. (personnel, indirect,
etc.) From the month's expenditure report
plus
(2) what is owing for services received in the month but not
yet paid (rent, for example, which might only be paid
quarterly) .
Divide the total of expenditures and obligations by the amount
budgeted for the line item. Determine whether the line item is
a fixed or a variable expense. Find the right column for fixed
or variable, and the right month for your calculations.
Compare the percentage you have as a result with the recommend-
ed percent spent for the month. This will tell you at a glance
whether or not you are staying within your budget limitations.
.-
'
X-123
3. Projections
After you have checked your current spending rate, you can also
project your expenses to the end of the fiscal year, including
in that figure any anticipated one time expenses. One time
expenses might include nutrition education materials not yet
purchased, funds set aside for a spring workshop, a June rent
increase and so forth. Projecting to the end of the year will
tell you whether or not you have left sufficient funds for the
one time as well as ongoing expenses, and will alert you to a
need to underspend a line item if it is necessary. It will
also help you to see that if you have overspent a line item
because of a one time expense (such as all the nutrition
education materials purchased at the beginning of the year) you
need to cut back on your spending in that line item until it is
back within the recommended spending rate.
Fixed expenses include personnel, indirect costs, rent, monthly
telephone charges, any expense that is unavoidable for the
operation of your agency. You are the best judge of which
expenses fit this category. Variable expenses include sup-
plies, travel, nutrition education materials, etc. These
expenses can be delayed, cut back, or in some cases even
dropped if additional funds are needed for fixed expenses which
are more difficult to control. By careful analysis of your
budget, you will be able to operate your WIC Program within
available funds.
4. Example
An example of an expenditure report and worksheet for figuring
out the spending rate follows. In this example, it is shown
that while $19,751 is shown as spent, obligated and spent is
$20,041, leaving a balance of only $4,166. In addition, the
line item "nutrition education" is overspent for the time
elapsed and expenditures in this category will need to be
watched to avoid overspending, particularly as there are no
funds evident in other categories to take care of any over-
spending. Obligations were incurred for April rent, April
telephone charge, a nutrition education film received, and
travel. These services are already received, but not yet paid
for.
X-124
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X-l-25
•
RECOMMENDED SPENDING PATTERN UNFORMATTED
1st Qtr Allocation
Total
Budget
Variable Expenses
Fixed Expenses
Recommended % Spent
Recommended % Spent
July
32.8
33.3
August
66.1
66.6
September
100.0
100.0
October
33.0
33.3
November
41.0
41.2
December
49.1
50.0
January
57.1
58.3
February
65.2
66.6
March
73.2
75.0
April
81.2
83.3
May
90.5
91.6
June
100.0
100.0
Variable Expenses: Travel, supplies, Nutrition Education, Repair, etc.
Fixed Expenses: Personnel (and indirect), rent, telephone services, etc.
X-126
VI. Fiscal Year-end Closeout
A. Expenditures must be separated and placed in correct fiscal years
for audit purposes. Fiscal year-end cut-off dates for WIC adminis-
trative expenses occur at June 30 (state contract year) and Septem-
ber 30 (federal year).
B. Procedures
1. The easiest, most direct way to account for Program expenses is
to pay them before the fiscal year ends:
a. Program expenditures for supplies, equipment, etc. should
be ordered two or three months prior to June 30 (state
contract year) or September 30 (federal year).
b. Receive and pay bills prior to June 30 or September 30
(fiscal cut-off dates).
2. Items which are purchased prior to fiscal year-end, but not
paid until after June 30 or September 30 must be listed on the
Accrual Report Form.
a. Complete the Accrual Report Form in addition to the
monthly expenditure report at fiscal year-end periods.
Submit both forms together to the State Agency.
b. When all items listed on the Accrual Report are received
and the bills paid, submit a revised final year-end
expenditure report and the final close-out Accrual Report.
c. Send final revised Expenditure and Accrual Reports to the
State Agency before September 30 and December 31 for
closing-out state and federal fiscal years respectively.
Any revised reports received after 90 days from fiscal
year-end periods are not eligible for payment with WIC
funds.
d. Inform the State Agency if no revised Expenditure Reports
are to be submitted at fiscal year-end periods.
3. Salaries, benefits and some bills (telephone, for instance) may
not be in your control. Those not claimed on your year-end
month's Expenditure Report must be listed on the Accrual Report
to be paid out of what becomes the prior fiscal year.
G
X-127
Supplemental Food Program for
Women, Infants and Children
MONTANA WIC ACCRUAL REPORT
Local Agency:
Date:
Check if State Fiscal Year (June 30):
OR Federal Fiscal Year (September 30)
REMEMBER: Submit this report with your year-end Expenditure Report (due 30
days after the end of a fiscal year). A revised closeout Expendi-
ture Report listing all accruals as paid expenses is due within 90
days after the end of the State or Federal Fiscal Years. -List the
paid accruals in the adjustment column of your revised report and
attach a completed copy of the Accrual Report.
Description Date Ordered or Amount Paid Date Amount
the of Expense Expense Incurred Accrued of Accrual Paid
Total Accrued Total Paid
X-128
ilTORING
I. DEFINITIONS
II. MONITORING PROCEDURES
A. State Monitoring of Locals
B. State Agency Monitoring Checklist
III. LOCAL AGENCY SELF-REVIEW
IV. LOCAL AGENCY EVALUATION OF STATE AGENCY
A. Evaluation Form
i
X-129
MONITORING SECTION
- Definitions -
Audit: Examination of the fiscal aspects of WIC for compliance with good
accounting principles set forth by USDA and SDHES.
Management Evaluation: USDA's term for reviewing the State Agencies' operation
of WIC.
Monitoring: State staff review of local agency program operation.
Monitoring Protocol: Explanation of the procedure followed related to monitor-
ing.
SDHES: Montana Department of Health and Environmental Sciences. Montana's WIC
Program operates out of the Health Services Division of SDHES.
Self-Monitoring: Local agency reviewing its own program operations.
Sites: Locations within a county or reservation where drafts are issued to
participants.
X-130
MONITORING PROCEDURES
State Agency Monitoring of Local Agencies
e
Purpose: The State Agency staff will perform on-site reviews of all local
agencies annually at a minimum of 50% of their sites. These visits will
determine compliance with Federal Regulations and State policies and
procedures, local agency nutrition education plans, as well as evaluate
program quality, and provide assistance to facilitate program improvement.
Levels of Responsibility
Federal : The Regional Office of USDA will perform a management evaluation
of the State Agency every two years which includes on-site visits to a
representative number of local agencies.
State: The State Agency shall monitor and review the performance of all
phases of the local WIC Program every year.
The State Agency shall inform USDA of unresolved problems, delays or
adverse conditions.
The State Agency shall provide technical assistance and training to local
agencies when necessary and applicable for resolution of monitoring rec-
ommendations.
A State Agency staff consisting of a Dietitian and either the Program ~
Coordinator or Administrative Officer visit the local agency to review
their records in conjunction with local agency staff.
The Monitoring Worksheet on page X- 136 sets forth the questions that will
be used to review the WIC records.
Local : The local agency shall maintain the required records for each
participant.
The local agency records shall be available to State and Federal agencies
for monitoring.
The local agency shall respond and follow-up on recommendations made by the
Federal, State or local agency as a result of a monitoring visit.
Monitoring Visit Procedures
1. The State agency staff conducts an entrance interview with local agency
personnel before the monitoring.
2. A representative sampling of participant records is selected for review.
3. The State staff conducts an exit interview with the appropriate local
agency staff and gives a verbal report of its findings. A discussion of
improvement from past visits, resolutions of problems, non-compliance
and/or revisions in procedures is appropriate during this interview.
c
X-131
4. Within 30 days after the visit, a written report of the State agency's
findings and recommendations is sent to:
a. Local Health Officer/County Commissioners;
b. Local agency Dietitian and/or Program Manager; with
c. Carbon copies to Clinical Programs Bureau Chief and Health Services
and Medical Facilities Division Administrator.
5. Within 30 days, the local agency shall respond to the monitoring report
stating when corrections, revisions or compliance have been or will be
accomplished.
6. If the local agency's corrective action plan is deemed appropriate, and no
further actions for correction are needed, the State Agency will acknowl-
edge in writing that the local agency's respunse is acceptable.
If major areas of concern remain uncorrected or are not addressed in the
corrective action plan, a follow-up visit may be scheduled.
X-132
NUTRITION REVIEW
ON-SITE VISIT
r
CHART AUDITS. COMPLIANCE REVIEW
Select a sampling of WIC client clinic records to audit for compliance with federal regulations,
Montana State WIC Program plan and associated issued policies. Strive to review records of a minimum
of 5% of total persons currently certified eligible. Plan to review records of a minimum of 10% of
total persons certified ineligible within the past year.
1. Is physical data correctly recorded and plotted? [246.7 Certification]
2. Is dietary record present, evaluated correctly, signed, and dated for each certification? [246.7
Certi f ication]
3. Is health history information (from well child or prenatal visits) available for use in the
nutrition assessment of the applicant? [246.7 Certification]
4. Is certification signea by registered dietitian? [Montana WIC Program State Plan]
5. Are notifications of health services documented as having been provided to the client? [246.7
Certification]
6. Are basic contacts provided and documented for each certification? Are. all nutritional risk
factors identified? Priority correctly stated? Person correctly certified with respect to risk?
[246.9 Nutrition Education]
7. Are secondary/high risk contacts provided to the highest risk clients? Do secondary contacts
address the nutrition problems identified? Is a written nutrition care plan present for all
high risk clients? [246.9 Nutrition Education]
8. have the proper number of vouchers (maximum 1 food package per month) been issued during a
certification period? [246.8 Supplemental Food]
9. Is food package prescription present? Is it based on identified nutrition problems? Do the
issued vouchers match the written prescription? [246.8 Supplemental Food]
ADDITIONAL ITEMS TO BE REVIEWED
1. Is a written caseload management plan present? Does it include a written plan of outreach?
[246.7 Certification]
2. Is there a waiting list? How is the waiting list handled? [246.7 Certification]
3. Select a sampling of records to audit for assessment, identification, planning and management of
a specific nutrition problem.
4. Review protocols for referrals to physicians and other health care providers.
5. Review plan for outreach goals and objectives.
6. Review local agency health services, policies and procedures.
7. Review local agency professional, technical references and resources for use in planning and
managing nutrition care of patients.
8. Discuss possible plans for improving accuracy of dietary intake assessment in your clinic. What
computer resources could be considered?
9. Review" together various aspects of the Montana WIC Program Policy and Procedure Manual. What
problems or discrepancies have been encountered? What edits, additions or corrections are
suggested?
10. What innovative management methods, protocols or plan of nutrition care have been aeveloped that
could be shared with other agencies?
WIC Program
Nutrition Services
Montana State Department of Health and Environmental Sciences
I
MM/war-80
March 1, 1985
X-133
NUTRITION REVIEW
WIC PROCRAtt
PRELIMINARY WORK PRIOR TO ON-SITE VISIT
1. Review most recent report RP14002 WIC CERTIFICATION SYSTEM, FAMILY NUMBER LIST OF CERTIFIED
ELIGIBLE CLIENTS for the clinic. Select 10 clients who have compound or complex nutritional
problems. Review relevant literature references and suggested nutrition care plans. Prepare for
discussion of these cases with the local agency dietitian.
2. Review most recent report RP1<*003 WIC CERTIFICATION SYSTEM, NUMBER OF OCCURRENCES OF NUTRITIONAL
PROBLEMS for the clinic. Note the ten nutrition problems which show to be occurring most often
at the time of certification of the clinic population. Select five of these nutrition problems
for discussion with the local agency dietitian.
3. Review most recent PEDIATRIC NUTRITION SURVEILLANCE reports. What nutrition problems occur at a
rate higher than the statewide average? At a rate lower than the statewide average?
<*. Review annual NUTRITIONAL HEALTH PLAN of the local agency. What objectives are described for
WIC? What dates are set for accomplishment of those objectives? Whet assistance, if any, was
requested? What assistance can be provided?
5. Review local agency WIC caseload management plans. Does the plan adhere to federal regulations,
state plan and state policy and procedure manual? Does the plan provide for persons of the
greatest nutritional risk to be served first?
6;' Review WIC food package costs for clinic for the most recent period available. How does this
clinic compare with other clinics?
7. Review recent history of duplicate WIC vouchers, lost and unused vouchers. Note family and
member number of vouchers involved, and the local agency explanations given.
S. Review recent correspondence files. Note relevant unanswered or unfinished business needing
attention. Plan how it will be addressed.
9. Communicate with state agency WIC staff regarding recent problems or new information which is
relevant and helpful to an on-site review.
10. Contact the SDHES nursing consultant for that region and request briefing on recent activities in
this local agency, which may have bearing on the planned visit.
11. Know the names of current local agency nutrition staff, their positions, and their general
responsibilities. Know the names of community health nurses, health officer or tribal board
chairperson, key direct health service providers in the area, and others as appropriate.
HM/war-80
March 1, 1985
X-134
WIC Local Agency Monitoring
Administrative Services
Worksheet
Agency:
Address:
Telephone:
Agency Code:
No. of Sites:
Office Hours:
Confirmed Visit Date:
Location:
Project Director:
Project R.D.:
Health Officer:
Service Unit Director (If applicable)
Current Fiscal Year Contract Amount:
Section I. State Agency Records
Regulation
Reference
Item
Yes
No Initials
246.6(a)
Current signed agreement on file?
Date signed:
1. Current signed satellite agree-
ment(s) on file?
County and Date(s) signed:
246.12(f)
246.12(i)
Current Vendor contracts on file?
Any outdated? #_
Which ones?
Current Vendor monitoring reports
on file?
#
Any outdated? #
Which ones?
c
X- 135
Regulation
Reference
Item
Yes
No
Initials
246.6(b)(6)
246.25
Are monthly participation reports
received on time?
Comments:
Are daily log sheets received on
timely basis?
Comments:
246.13(a)
-D.
Are expenditure reports submitted
time in accordance with negotiatec
Agreement
Comments:
on
Are expenditure reports accurate?
Comments:
2. Were any expenses since the last
monitoring visit questionable?
Describe (with date of report):
246.14(c)(1)
Are nutrition education expenses docu-
mented?
246.6(b)(6)
246.25
246.7(b)(4)
F. Are certification
timely basis?
records received on a
y-i.ifi
Regulation
Reference
Item
Yes
No
Initials
1. Are they accurate and complete?
Comments:
246 12(N),(s)(ii) G. Are the draft exception lists kept up
246 '.13 ' t0 date?
Comments:
1. Are the 60 day deletions kept up
to date?
Comments:
How many stop payments and voids
were received from this Agency in
the last three months?
Comments:
246.12(0(1)
H. What problems with local vendors are
evident from drafts cashed?
1 How has the local agency responded
to notice of such problems, if any?
246.12(0(2)
2. List specific high-risk vendors to
be monitored:
X-137
Regulation
Reference Item Yes No Initials
Title VI 1964 I. What was the ethnic breakdown of partici-
Civil Rights pants as given in the last racial ethnic
Act 246.4(a)(19) report?
1. How does this compare with the local
population listed in the latest
census report?
246.3(b) J. Were staff in attendance at the last
state workshop?
Comments:
246.20(d) K. When was the last independent finan-
cial audit conducted?
By whom?
Copy to State Agency?
Inventory Control Worksheet.
List # of State owned equipment to be
checked:
General comments to assist monitor:
(Include note of any fair hearing claims,
vendor or participant abuse cases, etc.
in the last year, or anything else that
should be monitored locally) including
issues addressed in the last monitoring
report or audit.
Comments:
X-138
Regulation Yes No Initials
Reference item
Section II. Local Agency On-Site Review
A. Persons present at entrance conference.
Comments:
B. Facilities. (Repeat for each site)
1. Where is the clinic conducted?
Describe:
2. How close are the facilities to
adjunct health care?
3. Is space adequate for the WIC
activities?
4. What geographical area does this
clinic serve?
5. Is this consistent with the ser-
vice area of the Agreement?
X-139
V
ii
Regulation
Reference Item Yes No Initial
246.8 C. Office Management
1. Are the office hours posted?
List if different from state
agency record:
2. Are the Civil Rights poster
and Fair Hearing procedure
posted in a prominent place?
If not, where are they currently
located?
Describe the problem with that
location:
246.25 3. Are the following present easily
246.6(b) accessible to staff:
a. Current WIC regulations?
b. Current State Plan?
c. Current Policies and Proce-
dures Manual?
d. Copy of current satellite
Agreement(s) , if any?
e. Vendor files?
246.25(a) - 4. Is the file organization clear and
understandable?
a. Do the files demonstrate
coordination of data collec-
tion, if applicable?
Notes and comments on file
organization:
5. Are client files and certification
record reports kept in a secure
place (locked file, safe, etc.)?
Who has access? List:
X-140
Regulation Yes Ko_
Reference ■
246.13(a) D- Inventory
1 Is state owned equipment ta9Qed
(greater than or equal to $200).
Can you account for all numbers
listed on the inventory control
worksheet? ,
List any that cannot be located.
If the equipment is not located
in the WIC clinic area, where is
it located?
#
Location
#
Location
#
Location
Any comments about the operating
condition of the equipment?
246.12 E. Drafts Management
1 Are drafts kept in a secure place
(locked cabinet or safe)?
2. Who has access? List:
Is a physical inventory conducted
every month to track draft usage _
and account for any discrepancies:
-
X-Hl
Regulation
Reference Item Yes No Initials
246.8 F. Civil Rights
Title VI 1964
Civil Rights Act 1. Is the non-discrimination clause
246.4(1) (a) (16) on all forms used by clients?
2. If there are significant number of
limited English or non-English
speaking participants, are adequate
materials and translators available?
Describe - attach samples if applic-
able:
Does the waiting list reflect the
ethnic make-up of the currently
certified eligible participants?
If it does not, how does it deviate?
4. Are certification records for all
participants denied program bene-
fits on file?
5. Are denied applications dispro-
portionately composed of minority
appl icants?
Comments:
Are these separate waiting facili-
ties for the purpose of segregation?
Are operational procedures (certi-
fication process, office hours,
etc.) designed in a manner that
does not have the effect of dis-
criminating against persons based
on race, color, or national origin?
X-142
Reaulation Vac M r..*+4»ie
Poforpnrp 1 LEill .
Reference
°46 12(f)(2)(x1(xv) 8. Are food vendors serving all per-
sons equally and are WIC program
participants treated the same as
other customers?
Comments?
246 4(a)(7) 9. Are a11 potential participants
advised of program availability
and eligibility stardards through-
out the year?
246 8 Title 10. Has training been provided and
VI 1964 Civil documented for all new employees
Rights Act and current employees to the extent
246 4(a)(16) that these persons are competent
• in Title VI Civil Rights Compliance
and Enforcement?
Describe the documentation:
246 3(d)(4) 11. Does the staff reflect the
Title VI 1964 minority make-up of the popula-
Civil Rights Act tion?
12. Does the staff know the proce-
dure for filing Civil Rights
complaints?
13. Have any complaints of civil rights
violations been filed against the
agency since the last monitoring
visit?
a. If any, how did the L.A. han-
dle the complaint? When was
it received?
When was it passed to the state
office?
246.7(d)(3) G. Waiting List
246.7(f) L „. .. .,
1. Is there a waiting list?
a,
How is it used?
b. Are there anv problems with
it?
X-143
Regulation
Reference Item Yes No Initials
2. How many are on the waiting list
by each priority?
I II III IV V
a. Average number of days on the
waiting list for each priority?
I II III IV V
246. 7(K) 3. Are transfers and migrants placed
ahead of all others on the waiting
list?
Other comments on the waiting list:
246.6(b)(7) H. Financial Management
246.13
Months and/or objects of expenditure
chosen for sample audit?
1. Describe method of bookkeeping.
2. Are receipts on file to document
expenditure reports?
a. Are they easily accessible?
b. Describe where and how they
are filed:
246.14 3. Are all costs examined allowable
WIC expenses?
If no, describe:
4. Do payroll time sheets support
reimbursement requests?
X-144
Regulation
Reference Item Yes No Initials
5. Has all staff time charged to WIC
actually spent on WIC program
activities?
Exceptions found:
246.3(d)(4), (e) I. Staffing
Is staff on payroll in line with
staff authorized in current Agree-
ment?
If not, what is the discrepancy?
2. Does the local agency use volun-
teers or others not paid by WIC?
If yes, in what capacities?
=
246.4(a)(13)(iii ) 3. What types of training are avail-
able to local WIC staff (for both
new employees and in-service for
staff).
Describe:
4. Are there any staffing difficulties?
Describe:
246. 12(f), (g) J. Vendors
1. Have all eligible vendors been
offered contracts at least once
annually?
X-145
Regulation
Reference
Item
Yes
No
Initials
246.12(h)
2. Describe the training that has
been provided to vendors since
the last monitoring visit.
a. When was the training pro-
vided?
b. What file documentation is
there for vendor training?
3. When are the price lists updated?
a. Date(s) of the current price
list(s):
General Comments:
246.12(k),(f)
4. Vendor Abuse/Problems
If there have been vendor
abuse or problems, how has
this agency attempted to
solve the problem (list tele-
phone, etc.). Describe the
problem:
X-146
Regulation
Reference Item Yes
b. Has the problem been resolved?
Is so, how?
c. Date of last visit to this
vendor?
d. Is documentation of the above
in the vendor's file?
Did local agency staff request
state assistance for this
problem?
Any other problems? If so,
describe:
Any state staff recommenda-
tions:
f. Attach monitoring notes of any
(high risk) vendors monitored
on this visit.
K. GENERAL COMMENTS
Persons Present at Exit Interview:
WIC State Staff Signature Date
DLT/dw/39b
X-147
WIC KCNITORING WORKSHEET
Clinic Name:
Clinic Number:
WIC PARTICIPANT'S RIGHTS AND RESPONSIBILITIES FORM
Family No.
Date Last
Certification
Date Latest
■ P R & R Form
Current?
Comments
•
-
DT/dw/30c
X-148
CI inic Name:
WIC MONITORING WORKSHEET
CI inic Number:
Financial Eligibility
Family &
Member No.
Certified
Eligible/
Category
Back-up
Document
Certification
Category
Correct
If not, what
should it be?
Comments
-
X-149
LOCAL AGENCY REVIEW OF THEIR OWN OPERATIONS
Purpose: Federal Regulations require that each agency establish a system by
which they review their own program operations and that of their satellites
annually.
What Criteria Shall Be Used for Review? The local agency may use the State's
rhprHict a mnHi fi rat i nn thereof, or a system which they
Criteria Shall Be Used for Review? The 1
Monitoring Checklist, a modification the
develop to review their program operations.
Documentation of Review: Local agencies shall maintain results of their reviews
on file for review by the State team during the annual monitoring visit.
X-150
Local Agency Evaluation of the State Agency Program Operations
Purpose: To help the State Agency determine what services are needed by local
agencies.
Who Completes: Local agency staff. It is not necessary that this report be
signed.
When Completed: Once a year to be sent to the State Office by March 1.
The State Office will summarize results and send to local agencies for
their information. The State Agency will also list how they will meet
suggestions for improvement.
X-151
SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS & CHILDREN (WIC)
MONTANA STATE AGENCY EVALUATION
WIC PROGRAM DATE:
LOCAL AGENCY EVALUATION OF STATE WIC PROGRAM OPERATIONS
INSTRUCTIONS: Please complete this form and return it to the State WIC Office
by March 1 , 198 . Please give a specific example when referring to a problem
and your recommendation for a solution. Please confine your comments to the
events in the last year and use additional sheets of paper as necessary.
I. ADMINISTRATION
A. Has your agency had sufficient input on Montana WIC Program policies
and procedures? If no, please give specific areas of concern.
B. Monitoring of Local Agency Operations
1. Do you feel the most recent assessment is fair? If no, please
specify concerns.
Available State Forms
1. Which forms could be made better? Please give specific recommenda-
tions.
2. Are form orders filled promptly? If no, please give
specifics.
D. Financial Assistance
1. Has your agency received adequate assistance in interpretation
and utilization of financial reporting forms?
E. Please list any suggestions for simplifying or improving the food
delivery system.
II. COMMUNICATIONS
A. Are collect telephone calls to the state office returned promptly?
B. Are memos from the state office:
1. Clear and concise? If no, give specifics.
X-152
c
2. Appropriately consolidated? If no, give specifics.
3. Too many? Not enough?
C. Has the state office listened to your program needs and complaints and
responded adequately? ___
D. Have you received conflicting information from state agency staff?
If yes, please give specifics. ■
E. Has the state agency staff been courteous in their communications with
you? If no, please give specifics.
III. TECHNICAL ASSISTANCE
A. Has the state agency provided sufficient technical assistance in:
Interpretation of regulations? If no, please give specifics.
B. Responding to local agency requests in resolving monitoring visit
recommendations?
C. Is technical assistance "problem oriented," e.g., does it meet your
agency's needs? If no, please give specifics.
D. Providing local agency training:
1. Please comment on the frequency and type of state agency workshops
you would like to attend: ~ - ;
2. Does state training meet your agency's needs? If no,
please give specifics.
E. Please comment on content, quality and quantity of nutrition assessment
materials provided by the state agency: '
(Signature of Person Completing Form) (Date Completed)
1/84-123
(
X-153
FORMS AND PAMPHLETS
INSTRUCTIONS FOR ORDERING
A. Preprinted f supplied by the State)
B. Special Orders
ORDER FORM
>
X-154
ORDERING FORMS AND PAMPHLETS
A. Preprinted: Fill in order form and send original and yellow copy to State
Office. Keep the pink copy for your records. Allow 2 weeks for delivery.
Supplies should be reviewed and ordered quarterly. You should keep a
3-month supply on hand. Supplies will be sent to you with a copy of your
order form.
B. Special Orders: If local agency has developed a WIC Program form or
pamphlet which meets a special need, it should first be sent to the SDHES
for approval and printing.
1. Send the State Office a neatly typed original or camera-ready copy
suitable for printing. Be sure to include the following statement:
"Rules for acceptance in the WIC Program are the same for everyone,
regardless of race, color, national origin, age, sex or handicap. If
you feel you have been discriminated against in any USDA-related
activity, write immediately to the Secretary of Agriculture,
Washington, D.C. 20250."
2. Specify the number of copies desired, weight and color of paper,
whether form should be printed on front only, or front and back, and
any other special instructions. Allow 4-5 weeks for printing and
mailing if form or pamphlet is approved.
MOTE: Special printings are dependent upon available funds.
-
X-155
»
Supplemental Food Program for Women,
Infants and Children (WIC)
Montana WIC ORDER FORM
DATE:
Agency Name:
SHIP TO:
Clinic Code:
Zip: 59
Date Needed (*):
(*) PLEASE ALLOW TWO WEEKS FOR DELIVERY
INSTRUCTIONS: 1) Fill in the amount requested. If a special order is being made, enclose the
original item or a photocopy suitable for reproduction, and specific instructions.
2) Send the white and yellow copies to the State Agency. Keep the pink copy for your
file; destroy upon receipt of the order.
3) All items (except special orders) will be back-ordered if not in stock and sent to
you as soon as possible. For special orders, please allow four-six weeks for delivery. All Special
Orders are dependent upon available funds.
LOCAL AGENCY
USE
FORM NAME
STATE AGENCY USE
AMT SENT/
DATE
PRIOR AMT
SENT
BACK ORDERED
DATE
AMT REQUESTED
COMMENTS:
White copy: State Agency
Rev. Tim
Yellow copy: State Agency Pink copy: Local Agency
X-156
Certification Record - I. 3 part certification record form.
Certification Record - II. Financial Statement.
Certification Record - III. Participant Rights and Responsibilities. <"~
Log Sheets
Progress Notes
Infant Boys Height/Weight Crowth Chart (0 to 36 Month)
Boys Height/Weight Crowth Chart (2 to 18 years)
Infant Girls Height/Weight Crowth Chart (0 to 36 Month)
Girls Height/Weight Growth Chart (2 to 18 years)
24-hour Recall and Diet History for Women
24-Hour Recall and Diet History for the Child 1-5
Infant Nutrition Assessment Form
Prenatal Weight Gain Grid
Prenatal Information Form
Documentation of Prenatal Care Form.
Nutrition Problems, Codes, Criteria and References for Public Health Nutrition Services. SDHES and
MDA. Reference Document.
Food Choices, The Montana WIC Program
WIC Authorized Food and Price List
WIC Vendor Application
WIC Vendor Agreement
WIC Vendor Monitoring Checklist
Monthly Blank Sight Draft Inventory Report
WIC Monthly Expenditure Report Form
WIC Draft Receipt Forms
Authorized Signature for Signing WIC Drafts
Nutrition Care Plan Form
Draft Exception List
Vendor Collection Letter
Stop Payment Request
WIC Order Form
WIC Participant Fraud Form
Individual Fair Hearing Procedures
Fair Hearing Card
Release of Information Form
WIC Ineligibility Notification Letter
Participant Questionnaire (Re: Vendors)
WIC Appointment Cards (Blue)
WIC Brochure
WIC Poster
Civil Rights Poster "And Justice For All"
Poster "We Accept WIC Vouchers"
Vendor Invoice
Order Form for Key Nutrient Pamphlets and Lesson Plans
"The First Twelve Months." Infant feeding guide.
Women: Foods for a Good Daily Diet
Children: Foods for a Cood Daily Diet
Vendor Address Labels
SDHES Address Labels
Montana State Department of Health and Environmental Sciences Revised 11/84
X-157
COMPLAINTS
I. COMPLAINTS
A. Acceptance
B. Time Limit
C. Information
D. Minimum Information Needed
E. Reporting Format
F. Notify State Agency
G. State To Notify Local Agency
H. Investigation
X-158
COMPLAINTS
COMPLAINTS
A. All written or verbal complaints about any part of the operation of
WIC in Montana shall be accepted and processed within 30 days of
receipt by the State or any local WIC agency.
B. Any person alleging improper treatment, discrimination or other wrong
doing must communicate to the State or any local WIC agency said
mistreatment within 180 days of the alleged action. (See Page 29 of
Section III.)
C. All complaints, written or verbal, shall be accepted. Information
submitted must be sufficient to identify the agency or individual
involved.
D. In the case of a verbal or telephone complaint, every effort should be
made to collect the following:
1. Name, address, and telephone number of complainant, or other
method of contacting the complainant;
2. Nature of the complaint;
3. Vendor name, if involved;
4. Local WIC agency, if involved.
E. No specific reporting form is required. However, a full record of all
contacts and activities related to the complaint must be maintained on
file in the receiving agency's office in order to track the action
taken to address the complaint.
F. Local agencies shall notify the State Agency of any ccmplaint(s)
received and request guidance for disposition of the complaint.
G. The State Agency shall notify a local agency of any complaint^
received concerning their jurisdiction.
H. Investigation and resolution of complaints will be handled on a
case-by- case basis, with all pertinent facts considered.
I. Complaints regarding discrimination will be processed according to the
instructions provided in Paragraph E, Page XV-3, of the Plan.
X-159
•
•
SECTION XIII
NUTRITION EDUCATION
X-160
NUTRITION EDUCATION
Pace
1. Introduction 8 XIII -1
2. Local Agency Nutrition Education Plan XIII-1
3. In-Service/Education of WIC Personnel XIII-1
4. Responsibilities of Local Agencies in Achievement of an
Effective In-Service Program XIII-?
5. Determining/Meeting Educational Need XI 1 1-2
6. Participant Instruction XIII -3
7. Nutrition Education Materials XII 1-4
8. Nutrition Education of Minority Populations XII 1-4
9. Client Input in Nutrition Education XII 1-5
10. Documentation of Nutrition Care XIII-5
*
I
X-161
NUTRITION EDUCATION
1. Introduction
a. Nutrition education is an independent component of the WIC Program,
equal in importance to the provision of dietary supplements and
dependent upon individual nutritional needs. It is provided as a
benefit of the Program at no cost to the participant. Nutrition
education within the WIC Program is designed to achieve the two broad
goals of:
i. Emphasizing the relationship between proper nutrition and good
health with special attention to the nutritional needs of
pregnant, post-partum and breastfeeding women, infants, and
children under five years of age, and
ii. Assisting the individual who is at nutritional risk to achieve
a positive change in food habits, resulting in improved nutri-
tional status and in the prevention of nutrition related prob-
lems.
2 . Local Agency Nutrition Education Plan
a. The local agency nutritional health plan is submitted as part of the
local agency's grant application. The plan addresses the following
areas:
I. Introduction. Scope of the Plan.
II. Evaluation of Previous Year's Nutritional Health Plan.
III. Interrelationship of Community Resources.
IV. Referral Agencies.
V. Description of Population Served.
VI. Data Describing Prevalences of Nutritional Problems.
VII. Objectives for Alleviating Nutritional Problems.
VIII. Materials and Resources for Nutrition Care of Clients.
IX. Nutrition Personnel.
X. Continuing Education and Training Needs of Nutrition Personnel
XI. Programs/Services Budgets.
XII. References.
3. In-Service/Education of WIC Personnel
a. Local agency staff involved in nutrition assessment and education will
fulfill their need for continual improvement and increased knowledge,
skills and abilities through training arranged and/or provided by the
state agency WIC staff and local agencies supervisors. Responsibili-
ties of the state agency in the provision of training opportunities
include:
i. annual training session for local staff and others involved in
nutrition assessment or education, designed to improve skills in
these areas,
X-162
ii. a nutrition communique, designed specifically as an update of
current nutrition issues and concerns,
iii. on-going provision of pertinent professional reading and other
material to agency nutritionists.
Responsibilities of the Local Agencies in the Achievement of an Effective
In-Service Program include at a minimum:
a. Encouragement of attendance by appropriate personnel at all training
sessions offered or arranged through the state agency,
b. Completion, when requested, of evaluations regarding the content and
benefit of education/training received,
c. Review of all recommended readings and nutrition background materials
provided to local agency staff by the state agency,
d. Development and maintenance of an active system which makes available
to all WIC staff the nutrition education materials provided by the
state agency.
Determining/Meeting Educational Need
a. The development of a plan of nutrition education for a client will
best meet the individual's need if based upon the following:
i. Nutrition problems identified; based on the following data:
individual dietary history or dietary recall
anthropometric measures
biochemical tests
clinical assessment
ii . Care Plan
Each individual client will have a care plan which addresses the
nutritional problem identified by the competent professional
authority, based on the data i.
This plan will include intervention, appropriate referral, and
follow-up.
iii. Professional's evaluation of likely response to individual
versus group counseling, provision of reading materials, level
of interest and comprehension, etc.
iv. Client's verbal expression of needs.
b. Individual clients shall not be denied supplemental foods for failure
to attend or participate in nutrition consultation or education
activities.
X-163
^
c. The plan for education over the six month certification period is
arranged with the client at certification and agreed upon as a mutual
responsibility to be accomplished through the program. Schedule for
educational contacts will be determined at the time of certification
and explained to the client.
d. In-home education sessions are conducted for high-risk participants
when necessary.
e. The plan for education will be supported by other involved health
professionals and appropriate agencies.
f. Client progress in meeting the agreed goals of the care plan will be
evaluated at the clinic visits and at time of recertification.
6. Participant Instruction
a. During each certification, all adult participants, the parent/guardian
of infant and child participants, and the children themselves when
possible, are provided, through individual or group sessions, a
minimum of two contacts as defined in the federal regulations.
b. A client contact must be made at the time of certification, and must
include all of the following:
i. Explanation of the client's nutritional risk condition and ways
to achieve adequate nutritional status and diet.
ii. For parents/guardians of clients, guidance in meeting the
dietary needs of the participant by a method appropriate to the
infant's or child's development, i.e., recommended infant
feeding practices.
iii. The nutritional contribution of the supplemental foods.
The importance of supplemental foods being consumed by the
client for whom they are intended in order to alleviate the
particular health condition.
iv. The purpose and benefit of WIC as a supplemental food program.
v. For all pregnant women, encouragement to breast feed.
c. The contact must be specifically and directly relevant to the identi-
fied nutrition problems, and must be appropriate to the client's
needs.
d. Important nutrition information is also sent to the participant's
primary health care provider whenever appropriate.
e. Additional client contacts must consist of instruction on one or more
of the identified problems discovered at the time of certification,
plus additional nutrition topics at the local agency's discretion:
X-164
i . The participant's particular nutritional needs according to the
category of eligibility, that is, pregnant, breastfeeding,
post-partum woman, and infant or child.
ii. The relationship of diet to health.
iii. The benefits of consuming a variety of foods in addition to
those provided by the program.
iv. Nutrients of special interest or need to the participant.
v. Desirable changes in eating patterns and methods for accomplish-
ment.
7. Nutrition Education Materials
a. The following reference books and materials have been supplied by the
Department for use in nutrition consultation to WIC clients, and must
be located on-site at each local agency:
i. Frankle, R.T. and Owen, A.Y., Nutrition in the Community. The
Art of Delivering Services, C.V. Mosbv Co., St. Louis, MO.,
1978.
ii. National Research Council, Food and Nutrition Board, Alternative
Dietary Practices and Nutritional Abuses in Pregnancy. Summary ♦
Report. , National Academy Press, Washington, D.C., 1982.
iii. Paige, David M., Clinical Nutrition, Manual of Clinical Nutri-
tion Supplement Vol. 3, No. 3, May/June, 1984.
iv. Pipes, P.L., Nutrition in Infancy and Childhood, 2nd edition,
C.V. Mosby Co., St. Louis, MO., 1981.
v. Reese, J. and Manahan, K., Nutrition in Adolescence, C.V. Mosby
Co., St. Louis, MO., 1984.
vi. Twin Cities Diabetic Association, Manual of Pediatric Nutrition.
Minneapolis, Minnesota. 1983.
vii. U.S. Dept. of Health and Human Services, Public Health Service
Centers for Disease Control, Nutrition Division, Health Services
Administration, Bureau of Community Health Services, Weighing
and Measuring Children: A Training Manual for Supervisory
Personnel , Atlanta, GA., and Rockville, MD. November, 1980.
8. Nutrition Education of Minority Populations
a. In providing equal and satisfactory nutrition education to migrant,
Indian, South East Asian, and other minorities, all of the policies
and procedures regarding instruction, participant input, and monitor-
ing of the educational process apply to the servicing of minorities
within the WIC Program.
X-165
b. Educational materials at the local agency can be made available in
foreign print as needed. Formal education for migrants is provided by
bilingual staff as necessary.
9. Client Input In Nutrition Education
a. Clients are provided the opportunity for input into the nutrition
education component of the WIC Program through the following prac-
tices:
i. Elicitation of client desires for receiving education on a
particular topic (design of the individual education plan) at
the time of certification.
ii. Provision of opportunity for written comment and evaluation at
least annually.
iii. Provision of opportunity for verbal comment or professional
questioning at all clinic visits.
iv. The nutritionist consults with the client prior to establishing
an individual nutrition care plan in order to best determine
concerns, educational needs, and willingness of the individual.
b. A program evaluation form to be completed by participants is distri-
buted to all local programs in January. The information is reviewed
by the local agency and returned to the state agency for evaluation
and for final review and compilation.
10. Documentation of Nutrition Care
a. Documentation of the consultation or educational contact must be made
in the client's record, and is retained as part of the client file.
Either a nutrition care plan form or the progress notes may be used
for this documentation. Where the information is located on the
■record is up to the local agency discretion, but should be consistent.
For each contact, the following items must be recorded:
i. The date, including the year.
ii. The name of the individual receiving the education; (will be
different than the participant's name in the case of an indi-
vidual, an infant or child).
iii . The content.
iv. The educational setting, i.e., individual or group or in-home
session.
v. The initial of the staff person providing the education. This
is not done until the participant has actually received the
education. This serves to verify receipt of the education. The
participant's refusal or inability to attend or participate
shall also be documented.
X-166
SECTION XI
FINANCIAL MANAGEMENT
7 CFR 246.4(a)(12)
"»
XI. FINANCIAL MANAGEMENT SYSTEM
Description of System
1. State Agency Responsibilities:
a. Make drawdowns against the letter of credit by "Request for
Funds" form TFS-5805. The amount of funds spent to date, as
taken from SBAS (Statewide Budget and Accounting System)
printout information, is subtracted from the accumulated total
of all funds received to date and on hand at the beginning of
the fiscal year. When this amount is low a request is made to
USDA for the estimated amount needed for no more than 3 days of
operation.
b. Determine distribution of food dollars and administrative funds
to Local Agencies. Administrative funds for Local Agencies are
determined by review of local program operations and local
budget requests.
c. Set up encumbrances upon negotiation of Local Agency contracts.
Once contracts have been negotiated and signed by all parties,
the State Agency sets up an encumbrance for the total adminis-
trative funds to be used by the Local Agency for the contract
period. Contracts in use are indicated in Appendix. 19 and 20.
d. Pay Local Agencies monthly in accordance with contract on
expenditure report and vendor invoice requests. Local Agencies
must send in expenditure reports with an accompanying vendor
invoice for the previous month's expenditures by the 15th of
the next month, unless other arrangements have been made.
Transfer warrants are used by the State Agency and payments are
received by the Local Agencies within the same month.
e. Maintain documented, accurate and ongoing reports of State
Agency expenditures via the SBAS system. Financial records are
maintained which account for all expenditures and letter of
credit withdrawals for the Montana WIC Program. The SBAS
System meets all basic accounting principles as outlined in 0MB
Circular A-102. The accounting system complies with all
general legal provisions and fully discloses the financial
position and results of financial operations of the WIC Pro-
gram.
The accounting system is organized on a fund/account basis
(accounting entity). An accounting entity is defined as an
independent fiscal entity with a self-balancing set of accounts
provided to record assets or other resources together with all
related liabilities, obligations, reserves and equities which
are segregated for the purpose of carrying on specific govern-
mental activities or attaining certain objectives in accordance
with specific regulations, restrictions or limitations.
All financial records and reports are prepared at least monthly
and at the close of each fiscal year covering all accounting
entities and financial operations of State government.
XI -40
As a rule, expenditures are charged to the fiscal year in which
they were incurred. Expenditures are recorded on the basis of
valid obligations when contractual agreements overlap fiscal
periods.
f. Determine budget for State Agency (see Section I, The 1988
Plan).
g. Operate data processing system for reconciliation of vouchers.
h. Pay food vendors.
i. Notify and request prior approval from FNS for any equipment
purchases exceeding $500.00
j. The Property Accountability Management System (PAMS) is the
inventory control system utilized by the Montana WIC Program.
Entries to PAMS are listed as a subsystem to the Statewide
Budgeting and Accounting System (SBAS).
The PAMS System lists:
a. Description of Purchase g. Funding Source
b. Inventory Number h. Inventory Date
c. Cost i. Condition
d. Acquisition Data j. Estimated Life
e. Used or New k. Program Assigned
f. Location
Local agency procurement procedures are listed on page III-C-31
of the WIC Policies and Procedures Manual.
3. Local Agency Responsibilities:
a. Submit line item budget requests for the contracting
period following guidance provided by the State Agency.
b. Submit monthly expenditure reports and vendor invoice
requests for payment.
c. Implement a financial management system that allows for
accurate, documented, on-going financial information on
WIC funds received and expended.
d. Provide accurate data for inclusion in the certification
and accounting systems by the State Agency..
e. Submit Nutrition Education accounting data during Septem-
ber, 1988, in the format described in Appendix 11.
XI-41
■
*
SECTION XII
DISTRIBUTION OF ADMINISTRATIVE FUNDS
7 CFR 246.4(a)(13)
XII. DISTRIBUTION OF ADMINISTRATIVE FUNDS
A. Start-up Funds
1. If and when expansion monies are available, any new local
agencies will receive start-up funds in accordance with DHES
contractual policy and applicable state law.
B. Advances
1. Advances are provided to local agencies in accordance with
standard contractual, encumbrance, and recovery policies of
DHES.
C. Administrative and Program Services Costs
1. Administrative awards to local agencies will be based upon
prior year expenditures and a review of the cost-efficiency and
cost-effectiveness of agencies including at a minimum, the
fol lowing:
a. Current staffing ratio for both certification and assess-
ment and nutrition education for your projected caseload;
b. Administrative cost per participant;
c. Utilization of in-kind services;
d. Administrative monitoring results and corrective action
plan completion;
e. Plan for reaching high-risk participants (Priorities I,
II, and III).
2. In addition, all local agencies will be evaluated subjectively
by State Agency staff in relation to actual expenditures; our
knowledge of recruitment activities and staff needs; number of
migrants served and clinics required for migrants; proposed
budgets; and any other pertinent special needs. This review
will constitute the basis for "discretionary awards."
3. The base grant and discretionary awards will be added together
to arrive at a total for a given fiscal year.
XII-1
SECTION XIII
FOOD DELIVERY
7 CFR 246.4(a)(14)
XIII. FOOD DELIVERY SYSTEM
A. Current System in Use
1. State Agency Responsibilities:
Provide a uniform food instrument (FI) which is similar in
appearance to a check. This document is used by all Local
Agencies. They are printed in duplicate and have a unique
numbering system - numerical sequence, by project number.
The date of issue, which is entered by local agency per-
sonnelis the first date the FI can be used by the partici-
pant. The last date the FI can be used to purchase the
authorized supplemental foods is 30 days from the date of
issue and is also entered on the face of the FI by the
project staff.
The FI shows the maximum value as $50.00 and lists the
foods authorized by generic and/or brand name, amounts and
estimated price. Space is provided for signature of the
participant. The first signature is obtained when the FI
is issued; the second is obtained when the participant
purchases the allotted food. This signature is used by
the food vendor for verification of identification.
WIC FI's contain pre-printed numbers at the bottom of the
FI (magnetic ink character recognition - MICR). These
pre-printed numbers identify the Federal Reserve Bank, the
local bank and the account number. After the FI is paid,
the amount paid is added by the bank. This coding allows
FI's to be sorted in clinic through the use of the county
numbering system, one (1) through fifty-six (56), and
seven additional numbers representing reservation pro-
grams.
Maintain an inventory of FI's on hand and order replace-
ment FI's as needed.
Payment to food vendors in a timely manner. The food
vendor is reimbursed when he presents the WIC FI to his
bank for payment within 90 days from the date of issue.
The FI's are then presented through the Federal Reserve
System to Norwest Bank of Helena, with whom we contract to
perform services. A contingent revolving fund has been
established for the WIC Program at the Helena bank. Each
day the bank presents the State Office with a statement
showing the amount of FI's paid. The bank is reimbursed
for this amount through the use of a telephone transfer
system.
Reconciliation of Food Instruments
(1) FI numbers, estimated prices and county/reservation
coding information are entered into the data system
from the log sheets received daily from local proj-
ects.
XIII-1
(2) Norwest Bank provides paid data including FI number,
county/reservation coding and amounts via electronic
data transfer daily with a request for input into the
data system.
(3) The issued and paid FI information are reconciled
each week upon request of WIC staff, and a printout
is sent to the WIC program.
(4) Upon receipt of this printout, the following lists
are checked for. errors:
(a) Control Totals: These are comprised of cur-
rent-week and current month issued, paid totals,
and outstanding issued per project. The control
totals also give the number of FI's issued and
paid per week and month.
(b) Exception List: These lists show the estimated
and paid total of any FI paid over the estimate
by more than 10%, or under the estimate by more
than 10%. This can occur if: I) the log sheet
is completed incorrectly, 2) the FI has an
addition error; 3) the vendor has allowed the
participant to receive more than the allotted
amount of food; 4) or the agency's price list is
not up-to-date. These lists also show the
corrections that have been made from data entry
errors on issued or paid FI's. All FI's cashed
over the maximum limit also show up on the
exception list.
(c) Unmatched Paid List: This is a list of any paid
FI which does not have a corresponding issue
date. When the reason has been identified as to
why the FI's are on this list, the necessary
corrections are made for input into the next
•data printout.
(d) Outstanding Issued List: The issues on this
list show the project, number and amount of the
FI. They remain on this list until the matching
FI is redeemed. If not redeemed within 60 days,
the issued FI is deleted and is then reported on
the deletion 1 ist.
(e) 0ver-6Q-Day Deletion List; The issued FI's
which are 60 days old are reported on that
week's data processing output. Each project
receives a copy of the control totals, the
over-60 day deletion list, and the exception
list each week for their project. These are
followed up by local personnel.
XIII-2
e. A monthly close-out is reported on the FNS-498
(Monthly Financial and Program Status Report). The
Montana WIC Core Accounting data system provides this
information ninety days after the month being closed.
The information for any month closed out includes
whether or not every issued draft has been redeemed,
expired, voided, or payment has been stopped. Records
in support of the FNS-498 are maintained in the State
WIC Office.
f. Vendors who untimely submit over $200.00 worth of
FI's for payment must await FNS approval through the
State Agency before payment.
2. Local Agency Responsibilities:
a. To issue FI's to eligible participants for authorized
foods. Local staffs fill in the FI with the date of
issue, the date no longer valid, the food vendor of
the participant's choice, the supplemental food
• authorized, the cost estimate of each food, and the
total estimated price in the spaces provided. The
staff member signs the FI and obtains the signature
of the participant. The participant then receives
the original of the FI . The copy of the FI retains a
copy of the signature of the participant, and these
copies are retained in the family folder for six
months and then discarded. The vendor fills in the
"pay exactly" column (see Vendor Agreement in Pol-
icies and Procedures Manual).
b. Fill out log sheets on issued FI's and send them to
the State Agency daily.
c. Obtain quarterly (or more frequently, as necessary)
price lists from local vendors for use in filling out
prices on the FI. It is important that prices used
are as current as possible so that the over estimate
rate can be closely controlled.
d. Maintain inventory of FI's on hand and notify the
state office when supplies are low.
e. Keep FI's locked up in a secure place. Local
Agencies are responsible for stolen or lost FI's via
the Local Agency Agreement (see Policies and Proce-
dures Manual). They are also responsible for report-
ing lost or stolen FI's to the State Agency so the
State Agency can handle the stop payment procedures.
Vendor Selection Criteria
(Please see pages VII 1-22 and VI 1 1-23 paragraphs 6 and 7 of Proce-
dure Manual .)
XII 1-3
/
C. Sample Written Agreement
(Please see pages VI 1 1-9 - VITI-12 of Procedure Manual .)
D. Food Vendor Monitoring
(Please see pages VIII -15 - VI 11-20 paragraphs 4 and 5 of Procedure
Manual . )
E. Food Instrument
1. A facsimile of the Montana WIC Program food instrument is
below:
STATE OF MONTANA
WIC PROGRAM
GOOD
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PAY TO THE ORDER OF
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PAY EXACTLY
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S50 00 MAXIMUM
o v
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MUST D£*OSlTMlTwir,60DA*S F BO"
VOID
DATE QF iSSU
*'C CUSTOMER SiuHATjBE
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>* lit io ?& s .»• iiosaoooaq&i:
MIC CUSTOMED COW*-TEnSICN*TiJBl(
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F. Reconciliation of Food Instruments
(Please see XIII, Food Delivery System, (A)(i)(d), above.)
G. Procedures to Pay Food Vendors
(Please see XIII, Food Delivery System, (A)(1)(c), above.)
H. Companies With Whom the State Agency Contracts
1. DHES currently contracts with Norwest Bank of Helena.
I. Plans for Improving Vendor Monitoring
1. Goal : To enhance preventive measures for reducing vendor
abuse.
a. Objective: By October 31, 1987, adopt a statewide Educa-
tional Buy Program for monitoring and training all high-
risk vendors.
XII 1-4
b. Objective: By October 31, 1987, improve on-site represen-
tative monitoring by including a comprehensive review of
vouchers on hand at each vendor, thoroughly investigate
client or staff complaints since orevious monitoring, and
require immediate follow-up to a corrective action plan.
c. Objective: By September 30, 1988, offer WIC Vendor
Education Exhibits to all major Montana food distributor
associatio-ns.
d. Objective: By December 31, 1987, analyze the Vendor
Activity Summary Report for additional statistical appli-
cations in identifying and prioritizing vendors suspected
of fraud and abuse.
e. Objective: By December 31, 1987, develop a client survey
questionnaire to be distributed on an annual basis to all
WIC participants. The survey should point out possible
vendor abuse and focus future training efforts on specific
vendor problems.
XIII-5
SECTION XIV
DUAL PARTICIPATION
7 CFR 246.4(a)(15)
XIV. DUAL PARTICIPATION
A. Description
Each month a report of possible dual participants is generated as a
part of the certification data output. Three copies are received
for distribution to both local agencies involved and a file at the
State Agency.
All clients receiving drafts are compared for birthdate, sex, last
name, and first four initials of the first name. When a potential
case of dual participation is identified, information about the
situation, including drafts issued, clinics where drafts were
issued, dollar amount, county of client residence, etc., is included
in the report.
B. Process
All reports are reviewed by State Agency staff to screen out obvious
inconsistencies like clinic errors and twins. Then an initial
telephone contact is made with the local agencies involved to
further screen out naturally occurring similarities.
Once potential dual participants are clearly identified, a copy of
the report is sent to the local agency for follow-up and action.
C. Action
Once the local agency is notified about a possible dual participant,
steps outlined in paragraph C, page X-83 of the Manual are imple-
mented.
XIV-1
SECTION XV
CIVIL RIGHTS
7 CFR 246.4(a)f 16)
XV. CIVIL RIGHTS REQUIREMENTS
A. Requirements
-
No part of the administration or service of the WIC Program in the
State shall exclude from participation in, deny the benefits of, or
subject to discrimination any person on the grounds of race, color,
national origin, age, sex or handicap.
In addition, Montana law requires no discrimination on the basis of
religion, creed, political ideas, or marital status. (MCA 49-2-303)
Program operations shall be in compliance with Title VI of the Civil
Rights Act of 1964, Title IX of the Education Amendments of 1972,
Section 504 of the Rehabilitation Act of 1973, the Age Discrimina-
tion Act of 1975, 7 CFR Parts 15, 15a, and 15b, and FNS instruc-
tions.
Public Notification
1. Outreach and Referral : Once a year all Local Agencies are
required to publicize the availability of benefits and eli-
gibility criteria to the general public. Agencies and private
groups serving minority populations are included in the out-
reach and referral network. State and Local Agency respon-
sibilities in this area are described in this section of the
State Plan.
When new sites or programs open or change hours of operation,
the Local Agencies involved are required to inform the public
of those changes.
During and just prior to the migrant season, special outreach
efforts are made to inform migrants of the availability of the
program. Outreach and referral activities are monitored by the
State Agency staff during the on-site monitoring visit and in
the review of the annual nutrition education plan which con-
tains an outreach and referral segment.
All outreach materials shall contain a civil rights statement
to the effect that: This is an equal opportunity program. If
you believe you have been discriminated against because of
race, color, national origin, age, sex or handicap, write
immediately to the Secretary of Agriculture, Washington, D.C.
20250.
2. Bilingual Staff and Materials: Bilingual staff or interpreters
are available for WIC projects serving participants who speak
Vietnamese, Laotian, Crow and other Native American dialects.
Spanish speaking staff is available during the migrant season
for those programs serving migrants.
Nutrition education materials are available in Spanish, Laotian
and Vietnamese. Also available is the Participants' Rights and
Responsibilities form in Spanish and Vietnamese.
XV-1
L
3. Non-discrimination Policies and Procedures. All Local Agencies
must display the poster "And Justice for All" in a place where
it can be easily seen by participants and potential partici-
pants .
WIC's non-discrimination policy is printed on the WIC Question-
naire- Certification Form, WIC brochures, press releases and
any materials that are seen or used by the participants or
general public.
The Fair Hearing Procedures and Discrimination Complaint are
provided to participants when they are determined ineligible
for the program. These are described in the State Plan,
Section One. Ineligible persons are provided with WIC regu-
lations and pertinent policy statements upon request.
Participants are informed of their rights and responsibilities
on the Questionnaire-Certification Forms and the Participants'
Responsibility Form.
C. Compliance Review
1. Local Agency Reviews
State Agency staff reviews all Local Agencies and at least 25%
of their sites annually. The monitoring checklist includes
questions on civil rights. During the on-site visit the state
staff checks the ineligible file for possible discrimination
and checks on accuracy of data collected for the most recent
FNS 191 Racial/Ethnic Report. The State staff makes recommen-
dations to Local Agencies based on monitoring findings. Local
Agencies are required to respond to the recommendations with
their corrective action plans which have been developed with
input -of State Agency staff. A follow-up on their action is
accomplished through additional conversations, correspondence
or visits as necessary. Copies of these reports are in the
files at the State and Local Agency.
All findings of non-compliance or probable non-compliance
related to Title VI will be forwarded to the Regional Adminis-
trator, MPRO.
2. Preaward Reviews of Potential Local Agencies
As part of the application review process, State Agency staff
will review applications according to the criteria outlined in
FNS Instruction 113- 2, IX, A, 2.
3. Vendor Reviews
All Local Agencies review every vendor agreement annually.
Exceptions to this policy must be approved in writing by the
State Agency. All vendor agreements contain a non-discrimin-
ation statement.
XV-2
D. Data Collection
Local Agencies are responsible for the collection of racial/ethnic
statistical information. The procedures used by the Local Agencies
are described below.
The Local Agency staff mark the Racial/Ethnic category of
applicants on the WIC Certification Record Form at the time of
application. The applicants are instructed that the data is
used for reporting purposes only and not for the purpose of
determining eligibility.
Local Agency staff transfer this information to the State
Agency at the end of the clinic day when food vouchers are
issued. The information is transferred to the FNS Form 191
annually by the State Agency unless otherwise ordered by the
Regional Office. FNS Form 191 reflects only those actually
receiving drafts, not all those actually certified. Data is
maintained for three years. This data is available only to
authorized personnel as a safeguard to prevent its use for
discriminatory purposes.
E. Complaints
Anyone alleging discrimination based on race, color, national
origin, sex, age or handicap has the right to file a complaint. All
complaints written or verbal shall be accepted and forwarded immedi-
ately to the Secretary of Agriculture or Director, Office of Advoca-
cy and Enterprise, USD A, Washington, D.C. 20250.
Any complaint regarding religion, creed, political ideas, or marital
status will be handled locally according to Montana law and proce-
dure.
F. Civil Riohts Trainina
The State Agency will update Local Agency staff by mail. The update
shall include all aspects of program operations, particularly:
1. Collecting and using data.
2. Effective public notification systems.
3. Complaint procedures.
4. Review techniques.
5. Resolution of non-compliance, including development of an
action plan.
XV-3
'
Assurances
All agreements entered into between the State Agency and Local WIC
Agencies contain assurances of Title VI compliance. Local Agencies
are monitored by the State to assure compliance to all terms in the
agreements.
A signed assurance by DHES that the agency shall comply with Title
VI is found in Appendix 10.
XV-4
-
SECTION XVI
FAIR HEARINGS
7 CFR 246.4(a)(17)
XVI. FAIR HEARINGS
A. Fair Hearing Procedure for Individuals
1. State Agency Responsibilities:
a. All requested fair hearings will be conducted by the DHES
within three weeks of the date the Department received the
request for the hearing. Those requesting the hearing
shall be notified in writing a minimum of ten days in
advance of the time and place of the hearing and of the
hearing procedure. The hearing will be conducted in
accordance with 7 CFR S. 246.9. The hearing will be
conducted by a fair and impartial hearing official, and
the appellant shall be notified in writing of the decision
of the hearing official and reasons for it within 45 days
of the receipt of the request for a fair hearing. All
decisions shall be based on facts found in the hearing
record alone, and the parties will be notified of their
right to appeal the decision to district court within 30
days. The hearing official's decision is binding on the
State Office and Local Agency, and if in favor of the
appellant, program benefits shall begin for an applicant
and continue for a participant within the 45 day limit.
b. If the decision is in favor of the Agency, any benefits
continued shall be terminated as decided by the hearing tf
official .
c. All records of the hearing shall be retained in accordance
with 7 CFR S. 246.15, and shall be available to the
appellant or representative.
2. Local Agency Responsibilities Include:
a. Informing each program applicant or participant of the
right to a fair hearing at initial and subsequent certi-
fications.
b. Notifying, in writing, applicants found ineligible; a copy
must be retained for Local Agency files.
c. Notifying in writing* each participant found ineligible at
any time during a certification period. A copy must be
kept in their files. The participant needs to be notified
a minimum of 15 days prior to termination of program
benefits. They must also be informed of their right to a
fair hearing.
d. Notifying each participant at least 15 days before the
expiration of each certification period that the period is
about to end. Local agencies, at the time of application
or when notifying persons found ineligible of their right
to a fair hearing, shall advise them of the method of
XVI-1
requesting the hearing, and their right to be represented
at the hearing by a friend, legal advisor, or other
representative of their choice, and give them a summary of
the hearing process.
Local agencies shall advise those found ineligible that
they have up to 60 days from notification of ineligibility
to request a fair hearing from the State Department of
Health and Environmental Sciences. The request for
hearing is defined as any clear expression by the indi-
vidual, guardian or other representative that an oppor-
tunity to present its case to a higher authority is
desired.
If a hearing is requested within the 15 day period by
participants found ineligible at any time during a certi-
fication period, benefits will be continued or reinstated
until a decision is reached in accordance with 7 CFR §.
246.9 or the certification period expires, whichever
occurs first. Applicants who are denied benefits at
initial or subsequent certifications shall not receive
benefits while awaiting the hearing. Local agencies
should obtain legal counsel to represent the program if a
hearing is requested.
A request for hearing shall not be dismissed or denied
unless:
1) The request is not received within 60 days from
notification of ineligibility; or
2) The request is withdrawn in writing by the appellant;
or
3) The appellant or appellant's representative fails,
without good cause, to appear at the scheduled
hearing; or
4) The appellant has been denied participation by a
previous hearing and cannot provide evidence that
circumstances relevant to Program eligibility have
changed in such a way as to justify a hearing.
XVI-2
TIME SEQUENCE FOR FAIR HEARING
ACTION
PARTICIPANT
STATE/LOCAL AGENCY
PROCEDURE
Participant notified
ineligible for WIC
benefits .
Participant has 60
days to request
fair hearing.*
Local Agency must
provide participant
with fair hearing
card & follow procedures
outl ined in Pol icy &
Procedure Manual .
Participant requests
fair hearing to State
Agency within 60 days,
Fair hearing is held
in county where
participant resides.
Participant appeals
decision.
Participant will receive
10 days written notice
of time and place of
fair hearing within 3
weeks of request.
Within 45 days of
original request
participant wil 1
receive decision by
hearings official .
Request must be made
to District Court
within 30 days of
receipt of written
notification of
decision.
Local Agency obtains
legal counsel to repre-
sent program at hearing
within 3 working days of
receipt of hearing request.
State Agency send fto
participant within 45
days) decision by
hearings official .
State Agency notifies
Legal Division of
appeals request.
*The participant who
fair hearing within
until a hearing decision is made
is terminated during a certification period and requests a
15 days of termination will continue receiving benefits
XVI-3
B. Appeals By Local Agencies and Food Vendors
1. Local Agency Responsibilities:
Informing the food vendor, in writing, of the right to a fair
hearing. The fair hearing should be requested within 60 days
of the date of denial or termination. The Local Agency shall
immediately notify the State Agency of a vendor's request for a
fair hearing. The Local Agency shall also inform vendors of
their rights in accordance with WIC regulations.
?. State Agency Responsibilities:
The State Agency, upon request for a hearing by either food
vendor or Local Agency, shall schedule a hearing and inform the
Local Agency or food vendor of the time and place, giving the
food vendor or Local Agency adequate advance notice. The State
Agency shall advise the- aggrieved agency of their rights under
the regulations. The hearing shall be conducted in Helena and
the Local Agency or food vendor will be informed in writing of
the decision and its basis within 60 days of the date of the
request for a hearing. The hearing shall be conducted by a
fair and impartial official, whose decision shall rest solely
on the evidence presented at the hearing and statutory and
regulatory provisions governing the program. The procedure for
the hearing shall provide at a minimum to the Local Agency or
vendor:
a. Adequate advance notice of the time and place of the
hearing to provide all parties involved with sufficient
time to prepare for the hearing.
b. The opportunity to present its case.
c. The opportunity to confront and cross-examine adverse
witnesses.
d. The opportunity to be represented by counsel, if desired.
e. The opportunity to review the case record prior to the
hearing.
f. The opportunity for two re-scheduled hearing dates.
3. Adverse action taken by the State Agency or Local Agency shall
be postponed until a hearing decision is reached. All appel-
lants denied program benefits at the State level shall be
informed in writing, along with the decision of the hearing
officer, of their right to appeal the decision to a district
court within 30 days of receiving the written notice.
4. Vendors shall be given 15 days advance notice of any adverse
action; including written notice of the action; cause(s) for
and the effective date of the action.
XVI-4
5. Local aaencies sha.1 1 , be . given .60 days advance . notice of .anv *
adverse' action, including written ' notice ot trie action",
cause(s) for and the effective date of the action.
6. Vendors shall be given not less than 15 days advance written
notice of expiration of the agreement.
7. Expiration of a contract with a local agency or vendor shall
not be subject to appeal .
-
"
XVI-5
SECTION XVII
TARGETING
7 CFR 246.4(A)(18l
•
XVII-6
XVII. TARGETING BENEFITS TO ELIGIBLE PERSONS r
A. Outreach through networking with agencies, groups and individuals as
described in Section VII, Availability of Program Benefits, will be
the preferred method of targeting benefits.
B. The State Agency has contacted other state WIC agencies for public
service announcements that have been developed for high risk
persons, receiving a series of television spots that are available
to local Montana WIC Programs.
C. The State Agency will continue to seek out materials and work with
agencies such as the Montana Perinatal Program and the Montana
Coalition for Healthy Mothers/Healthy Babies to assure that early
enrollment of high risk individuals into the WIC Program takes
place.
D. The State Agency will continue to work cooperatively with the
Montana WIC Medical Advisory Group to ensure professional
recognition of the targeting of benefits.
E. The State Agency will use other available media in outreach
activities, such as newspapers, newsletters, and radio.
F. The State Agency, recognizing the importance of agency/Program
cooperation, will continue to use available opportunities to educate
other health professionals to the WIC objective of targeting
benefits. ^
'
XVII-7
SECTION XVIII
POLICY STATEMENTS
DT/war-3 XVIII-1
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POLICY NUMBER 88-1
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENI OF POLICY:
Effective July 1, 1987, the income guidelines for WIC participants is based on
185% of poverty as follows:
Family
Size
Yearly
Monthly
Bi -Weekly
Weekly
1
2
3
4
5
6
7
8
Each additional
$10,175
$13,960
$17,205
$20,720
$24,235
$27,750
$31,265
$34,780
$848
$1,141
$1,434
$1,727
$2,020
$2,313
$2,606
$2,899
$392
$528
$662
$798
$934
$1,068
$1,204
$1,338
$196
$264
$331
$399
$467
$534
$602
$669
fami ly
add:
member
+ $3,515
+ $293
+ $136
+ $68
REFERENCES:
Federal
Register,
Friday, May 15,
1987
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3
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XVI 1 1-2
POLICY NUMBER 88-2
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Migrant workers who present current and official Verification of Certification
(VOC) cards will be issued food instruments at local WIC offices in Montana.
1. Each local agency's designated representative should examine the VOC card
and determine the applicant's eligibility.
2. In each case, the local agency shall record the issuing agency's name,
address, and phone number and place it in the applicant's family file
folder.
3. ' Immediately return the VOC card to the applicant.
REFERENCE:
7 CFR 246. 7(k)
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
Dl/war-3 XVIII-3
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POLICY NUMBER 38-3
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
MIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Each local WIC agency is assigned a maximum number of certified eligible persons
for the period July 1, 1987 through June 30, 1988, as follows:
Limit of Persons
County/Reservation Agencies Certified Eligible (per month)
Big Horn 180
Bl ackf eet 850
Broadwater 100
Cascade 1 , 200
Chouteau 80
Crow Reservation 600
Dawson 2 10
Deer Lodge 275
h lathead County 575
hlathead Reservation bOO
hort Bel knap 275
l-ort Peck tiOO
ba I latin 7b0
Glacier 80
Granite 50
Hil I ' -. 340
Eastern Plains 3^0
Lake 350
Lewis & Clark 9UU
Li ncol n 225
Missoula 1 ,810
Northern Cheyenne 450
Pondera 55
Ri chl and 155
Roc ky Boy 275
Sanders 200
Si 1 ver Bow 1,035
Sti 1 1 water 100
Teton 85
Val ley 175
Yellowstone 1,400
State Total 14 ,400
Rbi-hKENCE:
Signature, 'WIC Program Coordinator
Instructions: hi 1 e according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVI 1 1-4
wicp In
POLICY NUMBER 88-4
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Criteria for certification of applicants for WIC benefits will be assessed by
local agencies as follows:
1 . Summary of Certification Periods or Intervals:
a. Pregnant women shall be certified for the duration of their
pregnancy and for up to six weeks postpartum.
b. Breastfeeding women shall be certified at intervals of approxi-
mately six months ending with the breastfeeding infant's first
birthday.
c. Infants shall be certified at intervals of approximately six
months, except those Priority II and Priority IV.
d. Children shall be certified at intervals of approximately six
months and ending with the end of the month in which a child
reaches the fifth birthday.
e. Migrant and Priority I pregnant women must be given notice of
eligibility or ineligibility within 10 days of date of first
request for benefits. Expedited service is required.
2. 30-Day Leeway in Certification Dates: A time variation of plus or
minus 30 days for the certification intervals is permissible for
breastfeeding women, infants and children for the following reasons
only:
a. Participants are unable to be present at the normal certification
date;
b. Local agency wishes to coordinate data collection with other
programs, health professionals, etc.
The reasons for this time variation must be documented in the chart.
3. Changes Due to Birthdays: An infant becomes a child at one year of
age. However, she/he may have last been certified at 7, 8, 9, 10, or
11 months of age. There is no need to certify the child again at one
year of age, but the food package must be changed at that time from
the infant to the child's food package.
When a child turns five, food may be issued until the end of the month
of their 5th birthday.
DT/war-3 XVIII-5
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4. Biochemical Tests: Children who did not have anemia as a risk factor
at their last certification need only to have a hematocrit/hemoqlobin
test once a year. Those that did have anemia as a risk factor,
however, must have this biochemical test information available for
their next certification.
Local agencies may wish to retain the 6 month review of hematocrit/ -
hemoglobin for every child for specific reasons. If so, they need to
publish their own policy, sending a copy to the State Agency for
approval .
5. Matching Certification Dates: If the nutritional priority category
determination is based on data taken before the time of the entrance
on the program (see Application Section), then the date must be used
to calculate the certification intervals or schedule. This also holds
true for financial certification. If the financial information and
nutrition assessment data dates differ, then the earliest date shall
be chosen to calculate the certification intervals or the financial
information should be updated to coincide with the date of nutritional
problem data upon which the certification is to be based.
6. Back-up Documentation for Certification: For all identified risk
factors, back-up documentation must be available, either in the WIC
family folder or cross-referenced to the medical folder. This in-
cludes evaluated nutrition history information, such as the 24-hour
recall or Infant Nutrition Assessment, accurately plotted growth
grids, biochemical test scores, and health history information for
certain pregnancy risk factors or feeding problems identified in
infants or children.
7. Issuance of Food to Non-Certified Participants: If a participant
misses a certification appointment after the 30-day leeway, then no
food drafts can be issued to that participant or for that participant
until the certification process has been completed.
8. Assignment of WIC Applicants Into Priority Categories:
a. PRIORITY I: Pregnant Women, Breastfeeding Women, Infants
At nutritional risk as documented (demonstrated) by:
Hematological measurements, anthropometric measurements, or
documented nutritionally related medical conditions that
demonstrate the person's need for supplemental food.
DT/war-3 XVIII-6
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Code:
Pregnant
Woman
Breastfeed-
na Woman
Infant
0910
1211
0910
2200
1111
1211
1911
^
^
4>
2811
1113
1213
3210
0950
7900
0950
2813
1121
1266
3211
1115
1115
2815
1123
1300
3220
1125
1125
2816
1150
1350
Nk
1165
1165
3200
1162
1400
7999
1169
1169
4-
1166
1710
9400
1215
1211
2112
2113
2127
7999
9300
1168
1712
1900
1910
Exclude
Exclude
ExcU
de
4110
4680
2300
4680
5400
4111
4681
4110
4682
5500
4670
4684
4686
7230
4111
4160
4670
4684
4686
7230
PRIORITY II: Infants up to 6 months of age (except those in
Priority I) whose:
Mother was on WIC during pregnancy; or
Mother was NOT on WIC during pregnancy, but her medical
records document that she was at nutritional risk due to
nutritional conditions detectable by biochemical, anthro-
pometric measurements or other documented nutritionally
related medical conditions which demonstrated the person's
need for supplemental foods.
AND/OR:
A breastfeeding mother whose infant is Priority II
feeding Dyads) .
(Breast-
Code:
Pregnant Woman
Breastfeeding Woman
Infant
N/A
9300
9100
DT/war-3
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XVIII-7
PRIORITY III:
Children at nutritional risk as documented by hematological
measurements or anthropometric measurements, or other
documented medical conditions which demonstrate the child's
need for supplemental foods.
High risk post-partum women.
Code:
Children
High Risk
Post-Partum Women
1111 1211
1900
2127
1113 1213
1910
1121 1266
1911
1123 1400
3200
1150 1710
3210
1162 1712
3211
1166
3220
1168
7999
Exclude
3442
5400
5500
PRIORITY IV:
r
Pregnant women, breastfeeding women and infants at
nutritional risk because of an inadequate dietary pattern.
Code:
Pregnant
Woman
Breastfeeding Woman
Infants
0110
0611
0110 0621
0110 0682
0810
>l>
0612
4. 0622
4. 0721
>u
0580
0580 0681
0580 0782
0840
Exclude
Exclude
Exclude
0310
0310
0311
0320
0320
0321
0322
0322
0323
0325
0325
0326
0400
0400
DT/war-3
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XVII 1-8
PRIORITY V:
Children at nutritional risk because of inadequate dietary
pattern.
Code:
Children
0110 0682
0830
^ 0782
0850
0580 0810
0860
Exclude
0311 0326
0321 0400
0323
PRIORITY VI:
In the event that additional funding is made available to the
Montana WIC Program with which to serve post partum women at
nutritional risk, as Priority VI, the codes would be:
Code:
Post-Partum Women at Nutritional Risk
0110
0580
Exclude
0310 0325
0320 0400
0322
PRIORITY VII: The Montana WIC Program chooses to not serve
previously certified participants who might regress in
nutritional status without continued provision of supplemental
foods.
REFERENCE:
7 CFR 246.7
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3
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XVIII-9
POLICY NUMBER 88-5
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Infants will be certified in six month increments.
1. Infants certified before 6 months of age as Priority II and IV may be
certified to the end of the month of their first birthday. At a minimum,
length and weight shall be measured, and a hematological test for anemia
such as hemoglobin, hematocrit, or free erythrocyte protoporphyrin test
shall be performed at 6 months of age.
2. There may not be an extension of the certification end date for infants
certified Priority II or Priority IV.
3. If certified Priority IV after 6 months of age, certify at 6 month
intervals (change Food Package at 1 year).
4. Infants may not be certified for Priority II, 9100, after 6 months of age.
REFERENCE:
7 CFR 246.7(d), (3), (f)
Nutrition Problems, Code's, Criteria, and References, DHES and Montana Dietetic
Association.
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-10
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POLICY NUMBER 38-6
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
The Montana WIC Program serves Priorities I through V, with the following
exceptions:
1. No Priority V children may be certified eligible for WIC Program benefits
for more than two consecutive certification periods.
2. No Priority V client who has been graduated from the Program under this
policy may be certified eligible to receive WIC benefits in the future as
Priority V. Future participation is restricted unless or until medical or
anthropometric evidence is available which demonstrates eligibility in
Priority II.
REFERENCE:
7 CFR 246.7 Certification of Participants
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-11
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POLICY NLJMPEP 88-7
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Specific foods will be selected for use in the Montana WIC Program through:
1. A review by a panel of individuals to include the WIC Medical Advisory
Group; selected local WIC agency personnel; nutrition specialist, Montana
Cooperative Extension Service; State WIC staff; and a representative from
the Montana Dietetic Association; and
2. Criteria for food selection will include, but not be limited to:
a. Compatibility of the food's nutrition message with the Montana Child
Nutrition Education goals (e.g., what advertising claims are being
made? Is the food presented as a food, a staple, or as a prescription
.or confectionary? Is the advertising nutritionally and consumer-wise
sound and acceptable? Are prizes and gimmicks used to entice
purchase?) ;
b. Are costs competitive with currently authorized foods?
c. Oganoleptically acceptable (appearance appetizing? Food-like? Color7
Smell? Any added ingredients?)
d. Conceptual content of name (is it sexist? Is it violent in concept?1!
e. Professional determination, based upon experience.
3. Suggested changes to the authorized food list must be submitted in writing
by June 30 or December 31 of each year to the Montana WIC Nutrition
Education Coordinator, and must include:
a. A statement describing the change (addition or deletion);
b. A statement supporting the change (references, scientific research,
etc.);
c. A statement about how and why the change will impact the WIC Program
statewide.
4. The Nutrition Education Coordinator will review the request within 30 days
of receipt, requesting additional information within 15 days, if needed.
5. A letter to the submittor will be written within 45 days of receipt of the
request notifying of either approval or disapproval.
DT/war-3 XVIII-12
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The following foods are authorized for issuance in the Montana WIC Program:
INFANT Powdered
FORMULA
ENFAMIL
WIIH IkON 1 lb
ISOMIL
14 oz
LOFENELAC
2-1/2 lb
NURSOY
1 lb.
NUTRAMIGEN
1 lb
PHENYL-FREE
2-1/2 lb
PORTAGEN
1 lb
PREGESTIMIL
1 lb
PROSOBEE
14 oz
SIMILAC
WITH IRON, WITH WHEY (contains iron) 1 lb
SMA
WITH IRON 1 lb
SOYLAC
1 lb
Liquid Concentrate
•
ENFAMIL
WIIH IRON 13 fl oz
ISOMIL
13 fl oz
NURSOY
13 fl oz
PROSOBEE
13 fl oz
SIMILAC
WIIH IRON, WITH WHEY (contains iron) 13 f
SIMILAC
13 fl oz
SMA
WITH IRON 13 fl oz
Ready-to-Use
ENFAMIL
WITH IRON 32 fl oz
ISOMIL
32 fl oz
NURSOY
32 fl oz
PROSOBEE
32 fl oz
SIMILAC
WITH IRON 32 fl oz
WITH WHEY (contains iron) 32 fl oz
SMA
WITH IRON 32 fl oz
SOYLAC
32 fl oz
MILK
Fluid, Fresh
Vit D added, WHOLE 1 qt
Vit D added, WHOLE 1/2 gal
Vit D added, WHOLE 1 gal
Vit A&D added,
LOWFAT 1 qt
Vit A&D added,
LOWFAT 1/2 gal
Vit A&D added,
LOWFAT 1 gal
Vit A&D added,
SKIM 1 qt
Vit A&D added,
SKIM 1/2 gal
Vit A&D added,
SKIM 1 gal
Vit A&D added,
LOWFAT,
SWEET ACIDOPHILS
Canned
Vit D added, WHOLE, EVAPORATED
Vit A&D added, LOWFAT, EVAPORATED
Vit A&D added, SKIM, EVAPORATED
Vit D added, GOAT MILK, EVAPORATED
124 fl oz
DT/war-3
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XVI1I-13
Instant
i
Vit A&D adced, LOWl-Al,
DRY
Vit A&D added, NONFAT,
DRY
Vit A&D added, NONFAT,
DRY
CHEESE, natural
BRICK 1
lb
CHEDDAR 1
lb
COLBY 1
lb
LONGHORN 1
lb
MONIEREY JACK 1
lb
MOZZARELLA PART
SKIM OR WHOLE 1
lb
MUENSTER 1
lb
SWISS 1
lb.
LGGS, fresh
Grade "AA" Large
1 doz
CEREAL
Infant
8 qt, 16 qt
8 qt, 14 qt
14 qt
dry pack, no fruit or flavoring, RICE,
OATMEAL, BARLEY, MIXED OR
HIGH PROTEIN 8 oz
, 16 oz
Dry
COUNTRY CORN FLAKES
15
oz
KIX
9
oz,
13
oz
TOTAL
12
oz,
18
oz
CORN TOTAL
10
oz
CHEERIOS
7
oz,
10
oz, 15
oz, 20 oz
PRODUCT 19,
12
oz,
18
oz •
NATURAL BRAN FLAKES
16
oz,
20
oz
FORTIFIED OAT FLAKES
12
oz
LIFE
15
oz,
20
oz
LIFE CINNAMON FLAVOR
20
oz
CORN BRAN
12
oz,
16
oz
Hot,
Cooked, Plain or Regular
Flavor
Wheat Cereal
QUICK MALT-O-MEAL, Fortif
ied
Hot
24 oz, 28 oz
REGULAR, QUICK OR INSTANT
CREAM OF WHEAT
28 oz
ORIGINAL MIX N' EAT CREAM
OF
WHEAT
10 1-oz pkts
INSTANT QUAKER OATMEAL
10 1-oz pkts
i
QUICK CREAMY WHEAT FARINA
28 oz
JUICE (100% Juice, unsweetened)
Canned
•
ORANGE
46 fl
oz
GRAPEFRUIT
46 fl
oz
GRAPEFRUIT, PINK
46 fl
oz
ORANGE-GRAPEFRUIT BLENDED
46 fl
oz
Vit C added, APPLE
46 fl
oz
Vit C added, PINEAPPLE
46 fl
oz
Vit C added, VEG. JC COCKTAIL 46 fl oz
L
DT/war-3
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XVIII-14
Frozen Concentrate
ORANGE 12 fl oz
GRAPEFRUIT 12 fl oz
Vit C added, APPLE 12 fl oz
Vit C added, PINEAPPLE 12 fl oz
Infant
any plain or combination,
INFANT JUICE 8 fl oz jar, 4.2 fl oz jar
100% juice, unsweetened
LEGUMES Beans/peas, dried 16 oz
(Black, Black-eyed, Cow, Crowder,
Garbanzo, Great Northern, Split
Peas, Kidney, Lentils, Baby Lima,
Large Lima, Mung, Navy, Pinto,
Red, Small White, Small Red, Soy)
Peanut Butter 18 oz
Peanut Butter 18 oz
Peanut Butter 18 oz
Peanut Butter 18 oz
REFERENCE:
7 CFR 246.
Signature, WIC Program Coordinator
Instructions: File according to the- policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-15
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POLICY NUMBER 88-8
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
1. When a vendor runs out of a specific WIC food, the only allowable
substitution is another WIC food of the same category in an equal or lesser
quantity. Rainchecks or credit slips may be given only if an appropriate
substitution is unavailable.
2. Participants may not exchange WIC foods for non-WIC foods or exchange them
for other WIC foods. Participants requesting such exchanges should be
referred by the vendor to the local WIC agency. If spoiled or otherwise
unusable WIC food is being returned, retailers may only exchange returned
WIC foods for another WIC food of the same category on a one-to-one basis.
3. If the price of a substitute WIC food is greater than the original WIC
item, the vendor must also ensure that the total purcha-se price on the
voucher does not exceed the total estimated purchase price by more than
10%.
4. Clients are not allowed to purchase larger sizes of a WIC commodity and pay
the price differential. Only a WIC commodity of an equal or lesser
quantity as indicated on the voucher may be purchased; otherwise, excessive
price variance and abuse would result. Vendors are required to maintain
sufficient quantities and sizes of authorized foods in stock to satisfy WIC
demand.
FORMULA:
When breast-feeding is not chosen, the formula choices on the Montana WIC
Program are Enfamil with iron, Similac with iron, Similac with whey (contains
iron), and SMA with iron. These may be substituted, one for the other in equal
or lesser amounts; i.e., if the vendor is temporarily out of Similac with iron,
SMA with iron may be substituted.
Cow's or goat's milk will not be issued to infants under 12 months of age.
If the voucher is for an iron-based soy formula and the specified formula is.
out, substitution of a comparable soy formula is allowed.
Powdered iron-fortified formula may be substituted for the iron-fortified
concentrated formula or vice versa, as long as the correct quantities, calcu-
lated in fluid ounces, remains the same or less.
Iron-fortified ready-to-feed formula is issued (listed on the voucher^ only when
the competent professional authority determines and documents that there is an
unsanitary or restricted water supply, that there is no refrigeration, or that
the caretaker may have difficulty in correctly preparing concentrated or pow-
dered iron-fortified formula.
DT/war-3 XVI 1 1-16
wicpln
Certain other formulas are available and must be approved in advance by the
state WIC dietitian.
Formula may not be returned to the vendor unless it is found to be spoiled or
outdated. Excess formula must be returned to the WIC clinic. Participants who
request an exchange of previously purchased formula for another furmula must be
referred to the WIC clinic.
MILK:
Pasteurized whole, low fat, skim, dry powdered, and evaporated milk, which are
appropriately fortified with vitamin D and vitamin A, are the milk choices on
the Montana WIC Program. Substitution of these milks may be made only with the
authorization of the competent professional authority. The rationale for this
policy is based on the requirement of prescribed foods to meet specific iden-
tified nutrition problems of the client.
No flavored milk may be substituted. This includes chocolate milk, chocolate-
flavored milk, strawberry, etc.
CHEESE: .
Natural bulk cheese, any brand, are the cheese choices on the Montana WIC
Program.
"Cheese food" and "cheese spread" may not be purchased with WIC vouchers.
The cheese must be in a solid or brick form. Sliced, shredded, string cheese
and flavored cheese may not be purchased with WIC vouchers.
Natural Cheddar, Colby, Longhorn, Swiss, Brick, Monterey Jack, Mozzarella, and
Muenster are. the cheese choices on the Montana WIC Program. One may be sub-
stituted for the other in equal or lesser quantity.
American Cheese is not an authorized item on the Montana WIC food choices.
EGGb:
Grade "A" large or any smaller size eggs may be substituted.
INFANT CEREAL:
Dry pack, any brand (without fruit or flavoring) may be substituted in equal
quantity or less.
CEREAL:
Substitution of any combination of authorized WIC cereals may be made as long as
the total quantity does not exceed the number of ounces specified on the vou-
cher.
DT/war-3 XVIH-17
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JUICE:
100% juices, no sweetening added, are the Montana WIC Program juice choices.
Any brand of canned or frozen orange, grapefruit, or orange-grapefruit blend
juices that supply 100% vitamin C are allowed.
Seneca (in the red canj and IGA are the only approved brands of frozen apple
juices. Seneca is the only approved canned apple juice. Western hamily and S&W
Foods are the only approved vegetable juice cocktails allowed. Ihese brands
have vitamin C enrichment; others do not.
Fruit drinks, fruit-flavored drinks and ades, may not be purchased with WIC
vouchers. HiC, Hawaiian Punch, Tang, Orange Plus, Awake, etc. may not be
purchased with WIC vouchers.
DRIED BEANS OR PEAS:
Any variety of dried beans, peas, or legumes may be substituted for one another
in 16 ounce (one pound) quantities. Canned beans or peas may not be purchased
with WIC vouchers.
PEANUT BUTTER:
Any brand peanut butter is an acceptable substitution as long as it is no mure
than 18 ounces, and does not contain jelly, honey, or other sweeteners.
REFERENCE:
7 CFR 246.10
signature, WIC Program Coordinator
instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3
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XVIII-18
POLICY NUMBER 83-9
Effective Date July 1, 1987
health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENI OF POLICY:
Food products issued to meet clients' nutritional needs shall be the lowest cost
sources of those nutrients. Local agencies shall establish and implement WIC
food packages which meet this policy.
REFERENCE:
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
wiC policy and procedures manual.
UI/war-3 XVII 1-19
wicp In
POLICY NUMBER 88-10
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Each WIC participant certified eligible to receive Program benefits shall be
issued food instruments for redemption at designated food stores.
1. Food instruments written for less than $5.00 must be documented in the
participant's file and this documentation made available during annual
monitoring visits by the State staff.
2. Do not issue food instruments for over $45.00 so it will not exceed the
$50.00 limit when cashed.
3. Assign family number and member numbers for each instrument listed on the
log sheet.
4. If there are more food instruments than family members, repeat any member's
number.
b. Do not list a number on the log sheet for a family member who did not
receive a food package.
6. Issue enough instruments so that each member of a family receiving a food
package can be listed in a member space. For example, if there are four
family members receiving a food package, issue at least four food
instruments for the family.
REFERENCE:
-m<><<*^
Signature, WIC Program Coordinator
Instructions: Mle according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-20
wicp In
POLICY NUMBER 88-11
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
On-site monitoring visits will be conducted on at least 20 percent of authorized
vendors each year by local agency staff.
1. Local agencies will schedule visits so that all vendors are eventually
monitored. High-risk monitoring visits may be included as part of the 20
percent requirement.
2. Agencies with less than ten vendors will monitor a minimum of two vendors
each year.
3. All high-risk vendors will receive an annual on-site monitoring. A
standard monitoring form plus the Educational Buy Evaluation will be
completed for all designated high-risk vencors. It is suggested, but not
required, that the Educational Buy be completed at a different time than
when the standard monitoring is done on high-risk vendors. The state
agency will provide a listing of high-risk vendors to all local projects
annual ly.
KLFERENCE:
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIiI-21
wicpln
PROCEDURE FOR AM EDUCATIONAL BUY
Educational Buy - A WIC representative will use a voucher to purchase WIC
approved and/or non-approved foods. There is no penalty assessed against a
vendor for participation in an educational buy, although official warning
may be issued if the level of abuse warrants a response. The steps for
completing the buy include:
a. Fill in the voucher(s) used for educational buys at the WIC clinic
prior to monitoring the vendor. Complete the voucher correctly and
list it as a void on the log sheet. Indicate at the bottom of the log
sheet that the voucher will be used for an educational buy.
b. Contact the store manager/owner upon entering the grocery store and
explain the purpose of the monitoring. Maintain a cordial atmosphere
in this meeting to secure the vendor's approval and support. (Most
managers want to know if their checkers are correctly following
instructions) .
c. Explain to the vendor that an educational buy will be done to find out
how well-trained the checkers are in completing WIC transactions.
Mention that part of the items taken through the checkout may be
non-authorized foods, larger sizes of authorized foods, or non-food
items. Furthermore, explain that immediately after the purchase, you
will bring the food items back to the manager and go over the results
of the purchase.
d. The buyer should select food items and proceed directly to the cash-
ier. Do not mix personal items along with WIC items during this
educational buy. Remember, have a variety of eligible and non-
eligible items. The buyer will mention to the cashier that a WIC
voucher will be used to purchase the items before the transaction
begins.
e. The buyer should follow any instructions the store personnel may give
with regard to the transaction. Do not question or dispute any
instructions given by the clerk. Answer questions asked by the clerk
with an "I'm not sure", response. Do not argue or give a sob story to
the clerk. This type of coercion leads to entrapment.
f. After passing through the check-out counter and before beginning your
conversation with the store owner/manager, ask the vendor to go back
to the clerk and retrieve the voucher and void the transaction. After
the voided voucher is brought back to you, be sure to attach the
corresponding sales receipt.
Discuss the results of the buy and encourage the vendor to correct any
deficiencies found during this portion of the monitoring visit.
Complete Attachment A of the monitoring form and have the vendor sign
it. Give the vendor a copy of the report. If appropriate, the
reviewer may want to discuss the need for store personnel training at
DT/war-3 XVIII-22
wicpln
this time. Also be specific in detailing how and when the vendor is
going to correct any deficiencies. List deficiencies on the
monitoring report.
Put the grocery items back on the store shelves before you leave. It
is common courtesy to replace items used during an educational buy so
store personnel do not waste time putting items back.
A compliance purchase may be used as a follow-up to an educational buy
if evidence of improper vendor practices overwhelmingly contribute to
fraud and abuse.
DT/war-3 XVIII-23
wicpln
POLICY NUMBER 88-12
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STAThMtNT
STATEMENT OF POLICY:
Local agency WIC employees may also be WIC clients.
1. The employee eligible for WIC benefits shall not be the agency's authorized
signatory for her/his own WIC food instruments.
2. A supervisor must sign the drafts for employees participating in WIC. (The
supervisor must first obtain authorization from SDHES to sign WIC drafts.)
REFERENCE:
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-24
wicpln
a
POLICY NUMBER 88-13
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
MIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Price lists must be obtained or updated from participating food vendors on a
quarterly basis, or more often if requested by a local agency.
REFERENCE:
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3
wi cpl n
XVI 1 1 -25
POLICY NUMBER 88-14
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Redemptions of food instruments which exceed 10% of the estimated price
constitute a claim assessed against the food vendor.
1. Claims are assessed on exceptions with combined total, by vendor, of $10.00
or more for a period of three (3) months and for each individual exception
of $3.00 or more.
2. The difference between the actual price and the amount charged at the time
the food instrument was cashed is collectable.
.3. Exceptions below the levels in (1.) above are deemed not collectable.
4. Collectable claims are billed directly to the vendor by the Department of
Health and tnvironmental Sciences.
KLFERENCE:
Paragraph K of Vendor Agreement
7 CFR 246.12(s)(5)(iii), (s)(5)(i
7 CFR 246.14(e)
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
Dl/war-3
wicpln
XVIII-26
POLICY NUMBER 88-15
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Verification of income is required for confirming income eligibility for
certification to receive Program benefits.
1. First Attempt
An original document (check stubs, letter ofaward for unemployment,
Medicaid card, Food Stamp information, etc.) or a photocopy of such
document should be requested and if received, entered into the applicant's
file. The client should be aware that the document should be brought for
review and if necessary a photocopy may be made on the premises of the
local WIC office.
2. Second Attempt
If circumstances do not permit obtaining a photocopy of an original
document, visual observation by WIC personnel is acceptable. WIC personnel
must record their observation with the following written information:
a. Date of issuance of the document, time period covered or other
identifying information;
b. Document number, if any,
c. Gross dollar amount if not a qualifying program;
d. Who issued the document (source of income);
e. Who the document was issued to; and
f. Date of the observation and an initial or signature of the WIC
evaluator.
3. Such information should be entered on the financial statement form provided
by the State Agency, or otherwise attached to it in the file.
4. If no income is claimed by the applicant, a written statement of lack of
income should be obtained (may be prepared on the WIC premises at the time
of application), dated and signed by the applicant. The document should
then be entered into the applicant's file.
DT/war-3 . XVII 1-27
wicpln
5. 1 he applicant and local agency official must sign and date the financial
statement. Otherwise, the Financial Eligibility Statement is not valid for
certification purposes.
'
REFERENCE:
7 CFR 246.7(c)(2)(v)
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
<
DT/war-3
wicpln
XVIII-28
POLICY NUMBER 88-16
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
The following items require the non-discrimination statement:
1. Vendor posters which are developed by State and Local agencies and by
formula companies.
Vendor posters which will be posted publicly and which discuss program
eligibility would require the non-discrimination statement, regardless of
the source of finance. When circumstances are ambiguous, we suggest that
the decision to use the statement is prudent.
2. Media notices for vendor and local agency solicitations.
3. Newsletters, internal and inter-departmental, as well as those meant for
participants and/or other outside agencies.
If newsletters convey WIC benefits and participation requirements, they
most likely are a part of the notification process and should include the
non-discrimination statement.
4. Outreach and referral materials which are sent to physicians, hospitals,
social services and health care centers or to other professionals.
5. Letters of invitation to participate in the public hearing process which
are sent to organizations and other interested parties, and media announce-
ments of the public hearings.
The following items do not require the statement, but it is strongly recommended
that it be included:
1. Notices of warning or adverse action to participants and applicants, local
agencies and vendors, and employees or employment applicants. This would
include such items as notices of ineligibility or disqualification, and
cards or letters for missed appointments for food instrument pick-up or
recertifi cation.
There is no specific civil rights requirement that the statement be printed
on notices of warning or adverse actions or fair hearing procedures.
However, from a program standpoint, we strongly recommend that the state-
ment be included because the notices serve as notice of condition to
continued eligibility and convey the intent of fairness in the processing
of the action.
J
Dl/war-3 XVIII-29
wicpln
(
The following items do not require the statement:
1. Nutrition education materials such as posters and pamphlets.
Nutrition education materials which are developed primarily for nutrition
education, such as a poster on food preparation or a flip chart on the
basic food groups (but do not discuss or describe program benefits or
eligibility) do not need to have the statement included.
2. Participant ID cards, fact sheets, participant food instrument folders,
food lists for both participants and vendors, and other policy publica-
tions.
The non-discrimination statement is not required on participant identifica-
tion cards (ID), food instrument folders, or fooa lists for participants
and vendors unless these publications describe the WIC Program's participa-
tion requirements and benefits, in this case the non-discrimination
statement would be required.
Rationale:
This policy is in. response to a number of questions which have been raised
regarding the use of the non-discrimination statement. Clarification on these
issues has been provided by USDA.
State agencies are required to implement a public notification program to inform
participants and applicants, particularly minorities, of their rights and
responsibilities, their protection against discrimination, and the procedures
for filing a complaint. Therefore, any materials that provide information about
a federally funded program and the means of participation must contain the
non-discrimination statement if they will be distributed for or by a State or
local agency as a part of their public notification process. This policy
applies to brochures and any other literature, posters or visuals produced by a
participating vendor, a formula company or other interested party at its expense
relating tu program benefits and eligibility. Regardless of the intent, design,
or source of materials, it they convey messages concerning program benefits and
eligibility, and are used by State and local agencies to meet their required
public notification requirements, the non-discrimination statement must be
included.
REFERENCE:
7 CFR 246.8
A^^t^^pf- /kJk**<&
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVIII-30
wicpln
POLICY NUMBER 88-17
Effective Date July 1, 19S7
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY SlATEMENT
STATEMENT OF POLICY:
The section of the Montana WIC Program Policy and Procedures Manual entitled,
"Financial Management," is hereby adopted as the official instruction for
financial management operations of local WIC agencies in Montana.
REFERENCE:
7 CFR 246.
Policy and Procedure Manual
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
Dl/war-3 XVII 1-31
wicpln
POLICY NUMBER 88-18
Effective Date July 1, 1987
Health Services Division
Department of Health and Environmental Sciences
WIC PROGRAM POLICY STATEMENT
STATEMENT OF POLICY:
Policies developed by local agencies for local operations must be approved in
advance by the WIC Program Coordinator. They must be written, dated and signed
by the local WIC agency project director. The policy format used by the State
WIC Office may be used by local agencies.
REFERENCE:
Signature, WIC Program Coordinator
Instructions: File according to the policy number in the policy section of your
WIC policy and procedures manual.
DT/war-3 XVI l 1-32
wicpln
APPENDICES
APPENDIX 1: Definitions Used in the WIC Plan
WIC DEFINITIONS
1. Caseload: A maximum number of persons certified eligible to receive WTC
benefits; assigned by the State Agency.
2. Competent Professional Authority: Means an individual employed by the
local agency authorized to determine nutritional risk and prescribed
supplemental foods. The following persons are the only persons au-
thorized to serve as a competent professional authority: physicians,
nutritionists (bachelor's or master's degree in Nutritional Sciences,
Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutri-
tion or Home Economics with emphasis in Nutrition), dietitians, regis-
tered nurses, physician's assistants (certified by the National Committee
on Certification of Physician's Assistants or certified by the State
medical certifying authority), or State or local medically trained health
officials.
3. Encumbrance: A designated amount of money set aside for a specific
purpose.
4. Food Package: Supplemental foods prescribed by a competent professional
authority for a WIC participant to meet demonstrated nutritional needs.
5. Food Vendor: Local grocer, dairy or other merchant who, through a signed
agreement with the Local Agency, provides WIC foods in exchange for the £_
WIC voucher.
6. Local Project/Program/Agency: Organizational body that provides WIC
benefits within a defined project area.
7. Migrant Farmworker: Means an individual whose principal employment is in
agriculture on a seasonal basis, who has been so employed within the last
24 months, and who establishes, for the purposes of such employment, a
temporary abode.
8. Monthly Participation: A total number of clients actually receiving
benefits in any month.
9. Nutrition Counseling: Individualized professional guidance to assist a
person in adjusting his daily food consumption to meet his health needs.
10. Nutrition Education: The process of teaching about nutrition, food
selection and preparation, and human health. It uses individual tutor-
ing, group instruction, demonstration and mass media techniques. The
objectives are to motivate and enable individuals or population groups to
make nutritious food choices.
11. Nutrition Services: Nutrition intervention planned for and provided to a
client, such as assessment of nutritional health status, counseling,
provision of nutrition information, prescription of a food package,
referral to other health, financial, or social services, and evaluation
of change in behavior, and nutritional health status. /
Appendix 1
Page 1
12. Nutritionist: A professional who is a registered dietitian and who
possesses a Master's Degree in either Nutrition or Public Health Nutri-
tion.
13. Line Items: Budget items such as salaries, fringe benefits, postage,
etc.
14. Potent i al Parti ci pants : Persons not certified on WIC but who are apply-
ing for WIC services, or who have been determined by some statistical
means to be eligible for WIC services.
15. Real location: Process by which USDA monies are moved from one state
agency which is spending at a lower rate and given to another state
agency that is able to spend the money more rapidly due to larger case-
loads.
16. Registered Dietitian: A registered dietitian is a professional who meets
the academic and experience requirements described in SB 289, 48th
Montana Legislature.
17. Retail Purchase System: A system in which the participant obtains WIC
foods through an authorized food vendor, i.e. grocer or dairy.
18. Satellite: A WIC program operated by another WIC program which has
primary administrative responsibility for a program and contracts direct-
ly with the State Agency. A satellite differs from a site in that it is
located outside the defined project area, i.e., county or reservation.
19. Site: Within a defined project area there may be more than one
site/clinic that offers services to WIC participants.
20. Staffing Pattern: Ratio of WIC staff needed to number of participants
served.
21. State Agency: USDA's administrative designee for WIC in the State.
22. State Plan: Requirement of the State Agency by USDA which indicates
action plans necessary to meet USDA regulations.
23. Voucher: Check-like document which is traded by the WIC participant for
food at his/her local vendor.
Appendix 1
Page 2
APPENDIX 2
FY 86 AFFIRMATIVE ACTION PLAN
ACTUAL CASELOAD BY PRIORITY FOR MARCH, 1986
A. A.
TOTAL ESTIMATED
%
Project
Rank
P-l
P-l I
p-l 1 1
P-IV
P-V
TOTAL
ELIGIBLE FOR 1987
SERVED
°Ye1 lowstone
1
363
94
430
53
53
992
3,596
27.59
"Cascade
2
477
86
389
62
132
1,146
3,518
32.58
°Mi ssoul a
3
472
93
726
55
154
1,500
2,404
62.38
"Fort Peck
4
199
76
462
13
2
752
564
133.29
"Flathead Co.
5
251
40
236
46
1
583
2,102
27.74
"Lewi s & CI ark
6
237
91
268
95
172
863
1 ,510
57.14
"Gallatin
7
182
38
203
42
29
494
1 ,439
34.32
"Silver Bow
8
212
46
282
38
185
763
996
76.61
+Ravalli
9
116
20
165
21
44
366
1,031
35.51
"Lake
10
121
9
152
4
28
314
1,063
29.53
"Blackfeet
11
215
78
537
17
48
895
652
137.36
"Hi 1 1
12
53
26
91
23
67
260
792
32.83
"Lincoln
13
35
34
77
42
33
221
796
27.78
Fergus
14
0
0
0
0
0
0
683
0.00
"Crow
15
158
52
307
28
110
655
648
101.09
"Richland
16
43
13
62
8
33
159
533
29.84
°N. Cheyenne
17
130
45
216
13
48
452
397
113.72
"Fl athead Res.
18
137
32
262
12
30
473
376
125.81
"Valley
20
24
6
18
2
31
81
562
14.42
"Custer
19
75
12
83
5
13
188
473
39.75
+°Rosebud
21
27
13
34
4
8
86
567
15.17
"Big Horn
22
57
4
98
6
15
180
816
22.05
+°Beaverhead
23
39
8
70
11
54
182
451
40.32
"Dawson
24
45
9
57
12
33
156
400
39.02
+Carbon
25
16
0
18
2
7
43
425
10.13
"Glacier
27
12
3
30
4
12
61
752
8.11
"Sanders
26
59
9
84
6
20
178
381
46.67
+°Blaine
28
11
2
22
4
13
52
508
10.23
+°Park
30
73
5
50
5
25
158
347
45.59
+"Phillips
29
15
10
7
6
37
75
411
18.26
"Teton
31
20
6
22
5
8
61
404
15.0*
102/
"Deer Lodge
33
67
26
114
27
87
321
315
Roosevel t
32
0
0
0
0
0
0
656
o.L
"Pondera
34
14
2
17
1
8
42
373
11.26
"Chouteau
35
14
12
20
1
12
59
341
17.32
+°Powel 1
36
35
3
44
5
28
115
308
37.37
"Fort Belknap
37
74
36
111
27
66
314
345
90.99
Toole
38
0
0
0
0
0
0
255
0.00
+°Jeff erson
39
24
9
23
10
17
83
228
36.45
Sheridan
40
0
0
0
0
0
0
251
0.00
Mussel shel 1
41
0
0
0
0
0
0
259
0.00
"Rocky Boy
42
42
30
94
18
52
236
311
75.78
Madi son
43
0
0
0
0
0
0
247
0.00
"Sti 1 Iwater
44
11
12
31
4
17
75
183 '
40.95
"Broadwater
45
27
13
33
6
6
85
189
44.95
Sweet Crass
46
9
1
9
11
16
46
182
25.26
"Mi neral
47
17
7
21
2
6
53
153
34.75
+°Fallon
48
9
1
9
11
16
46
150
30.69
Judith Basin
49
0
0
0
0
0
0
157
0.00
Daniels
50
0
0
0
0
0
0
153
0.00
+°McCone
52
1
0
1
0
6
8
149
5.38
+°Powder River
51
4
0
15
1
1
21
140
15.01
Liberty
53
0
0
0
0
0
0
138
0.00
"Granite
55
5
4
14
13
8
44
130
33.84
Wheatland
54
0
0
0
0
0
0
131
0.00
+°Carfield
56
3
2
3
0
0
8
119
6.74
♦"Prairie
57
0
0
2
0
2
4
124
3.23
Carter
58
0
0
0
0
0
0
112
0.00
+"Meagher
59
0
0
0
0
0
0
84
0.00
+°Wibaux
60
3
0
0
3
0
6
69
8.69
Golden Valley
61
0
0
0
0
0
0
73
0.00
Treasure
62
0
0
0
0
0
0
57
0.00
Petroleum
63
0
0
0
0
0
0
56
0.00
TOTAL 4,233 1,127
° = Currently operating the WIC Program.
+ = Satel 1 ite site
plan-3
wicpln
6,019
783
1 ,793
13,955
36,035
38.73
APPENDIX 2
Page 1
APPENDIX 3: Application Packet for Local Agencies
APPLICATION COVER LETTER
Dear
The Special Supplemental Feeding Program for Women, Infants and Children (WIC)
is designed to improve the health and prevent occurrence of nutritional problems
in low income, pregnant and lactating women and young children at nutritional
risk to age 5 by providing nutritious foods, nutrition education and referral
and follow-up to ongoing health care.
Your responsibilities as a local agency, should your application be approved,
would include:
1. Hire a competent professional authority to serve the Program, and employ
additional professional and clerical staff as appropriate for operation
of the Program.
2. Determine eligibility of applicants and certify those who are eligible
for Program benefits.
3. Issue food vouchers to participants.
4. Provide nutrition education to participants in accord with the nutrition
education plan and prescribed nutrition services standards.
5. Maintain financial, administrative and participant records.
6. Follow Federal and State policies and procedures.
7. Provide certain minimum health services to participants, including but
not limited to referral and follow-up to appropriate medical care.
The review for selection of local agencies to administer the WIC Program will
include, but not be limited to the following factors:
1. The applicant's position in the Montana WIC Affirmative Action Plan.
2. Adherence to 7 CFR 246.5. (Priority A: A public or private non-profit
health agency that provides ongoing routine pediatric and obstetric care
and administrative services; Priority B: A public or private non-profit
health or human service agency that will enter into a written agreement
with another agency for either ongoing routine pediatric and obstetric
care or administrative services; Priority C: A public or private non-
profit health agency that will enter into a written agreement with
Appendix 3
Page 1
private physicians, licensed by the State, in order to provide ongoing f
routine pediatric and obstetric care to a specific category of partici
pants (women, infants or children); Priority D: A private or non-profit
human service agency that will enter into a written agreement with
private physicians, licensed by the State, to provide ongoing routine
pediatric and obstetric care; Priority E: A public or private non-profit
health or human service agency that will provide ongoing routine
pediatric and obstetric care through referral to a health provider.)
3. The applicant's projected ability to meet WIC Program regulations and
State policies and procedures
4. The applicant's history of performance in other programs and in admini-
stering similar public health services.
5. The applicant's plan for providing linkages with appropriate health care
providers.
6. The applicant's ability to make the Program accessible to participants.
8. The applicant's financial integrity and solvency as demonstrated by
independent audits.
7. The applicant's projected cost of operations.
Call me at 444-4740 if you have any questions or wish additional information.
If your application is approved, we will offer you assistance in staff recruit-
ment, budgeting and provide orientation and training.
Sincerely,
David L. Thomas
WIC Program Coordinator
Health Services Division
DLT/war
Enclosures
Appendix 3
Page 2
FACT SHEET
The Special Supplemental Food Program for Women, Infants and Children, better
known as WIC, provides low income pregnant and breast feeding women, as well as
children up to age 5 at nutritional risk with:
1. Selected foods to supplement diets lacking in nutrients needed during
this critical time of growth and development.
2. Nutrition education and counseling to improve eating behaviors and
promote sound food buying habits.
3. Access to preventive health programs, and referral to private and public
health providers.
Who Is On WIC?
Over 12,000 women, infants and children from 39 counties and 7 Indian reser-
vations, for a total of 65 sites, are currently receiving WIC services. Many of
the families' providers are seasonal ranch workers, or loggers, the temporarily
unemployed and students.
How Does WIC Benefit Montanans?
1. Healthier women and children through prevention and identification of
nutrition-related medical problems. People with or at risk for iron
deficiency anemia, overweight, underweight, poor growth patterns and
faulty dietary habits are provided with appropriate education and refer-
ral to medical care.
2. $3,520,000 food dollars spent in local grocery stores and dairies in
Fiscal Year 1980. Fiscal Year 1985 will see $4,175,402 in WIC business
for local grocers.
3. Jobs for 96 persons in Montana counties and Indian reservations.
WIC benefits are provided to eligible participants without discrimination on the
basis of race, color, creed, political ideas, sex, age, marital status, physical
or mental handicap, national origin or ancestry.
Appendix 3
Page 3
AVAILABLE MATERIALS AND RESOURCES
Materials
The following materials are available from the State WIC Office:
1. Current State Plan of Operations.
2. Current State Policy and Procedure Manual.
3. Current Federal Regulations.
4. Current State Health Plan.
Resources
The following resources are available at the State WIC Office:
1. State WIC staff (available for on-site visits).
2. Census data.
3. Vital Statistics.
Appendix 3
Page 4
Supplemental Food Program for Women, Infants and Children (WIC)
Montana Application for Local Agencies
I. Instructions:
A. We suggest the applicant contact the Program Coordinator before
completing this application. It is possible some information may
not be needed, or that specific additional data is required. Early
contact between the applicant and the agency will help minimize
problems.
B. Please answer all questions completely.
C. Use the most current data available.
II. Applicant Information:
A. Applicant Agency Name:
B. Address:
C. Telephone:
D. Name, title and address of responsible official:
Type of Agency:
1. Public
2. Private, Non-profit
3. IRS Tax Exempt
#
4. IRS application pending (date submitted
5. Tribal
6. Other
III. Health Services:
A. Do you currently have a Well-Child service in your community?
B. If yes, describe:
If no, describe your plans to provide this service:
Appendix 3
Page 5
Do you currently have a Prenatal Education Program?
1. If yes:
a. Describe (use additional sheets if needed)
b. Is breastfeeding education part of the prenatal education
program?
Is there a linkage with the hospital to provide support
for the woman who chooses to breastfeed her infant?
Describe (use additional sheets if needed)
2. If yes, provide the following data:
a. Number of pregnant women served in last 12 months:
3. If no, describe your plans to provide this service:
E. Describe your plans to refer Program participants to a public agency
or private provider for follow-up on identified health problems,
including the procedure for feedback from the public or private
provider:
IV. Nutrition Services:
A. Provide the name of the individual who will act as competent profes-
sional authority:
B. Provide the qualifications of the person named above:
V. Socio-Economic/Vital Statistics
A. What will be your service area?
B. What will be your geographic service area?
C. What is incidence of:
1. Premature Infants
2. Miscarriages
3. Low Birth Weights
4. Teen Pregnancy
5. Other identified risks
D. What is the service area population?
Appendix 3
Page 6
E. What is the service area median family income?
F. How many families in your service area are on Aid to Families with
Dependent Children?
G. General Assistance?
H. What is the service area racial/ethnic composition?
1. White %
2. Black %
3. Hispanic %
4. American Indian
5. Asian or Pacific Islander %
6. Other %
I. What is the service area infant mortality rate?
J. What is the service area maternal mortality rate?
VI. Financial Eligibility
A. What income eligibility figures will you use to determine financial
eligibility for Well Child, Prenatal Education and Immunization
services?
VII. Projected WIC Caseload (Total individuals and Total families
(If possible, describe your projected WIC caseload in terms of the WIC
Priority System, thus:)
A.
B.
Priority I
Priority II
C.
Priority- III
D.
Priority IV
E.
Priority V
(Any description of the characteristics of the projected caseload, like
number of pregnant teens, older pregnant women, etc., are very helpful.)
VIII. Physical Location
A. Where will clients be served? (Be specific)
IX. Begin Date
A. When do you anticipate being ready to open a WIC clinic?
Appendix 3
Page 7
The applicant agrees that WIC Program benefits will be provided to eligible
participants without discrimination on the basis of race, color, religious
creed, political ideas, sex, age, marital status, physical or mental handicap,
national origin or ancestry.
The applicant further agrees and assures that if selected it will comply with
the WIC Program Federal Regulations and State Policies and Procedures for WIC
Program operations.
The information contained in this application for a WIC Program is
accurate to the best of my knowledge.
true and
(Date)
(Signature of Local Official Able to Authorize the
Implementation of a WIC Program)
Appendix 3
Page 8
APPENDIX 4: Description and Maps of Local Agencies
Local Agencies in Montana
Contracting
Local Agency
Address
Program
Code
Geographic
Area Served
No. of
CI inics
fas reported
to USDA/
Racial-Eth-
nic ReporO
1.
Big Horn Co.
WIC Program
809 North Custer
Hardin, MT 59034
021
Big Horn Co.
1
2.
Blackfeet
Reservation
WIC Program
Blackfeet Tribal Health
Dept.
IHS
Browning, MT 59417
591
591
Blackfeet Res.
Browning
Heart Butte
1
1
1
3.
Broadwater Co.
WIC Program
P. 0. Box 489
Townsend, MT 59644
041
041
Broadwater Co.
Meagher Co.
1
4.
Cascade Co.
WIC Program
Cascade Cy-Co Health Dept
1130 17th Ave. S
Great Falls, MT 59405
. 071
Cascade Co.
1
5.
Chouteau Co.
WIC Program
P. 0. Box 475
Fort Benton, MT 59442
081
Chouteau Co.
1
6.
Crow Agency
WIC Program
PHS Hospital
Crow Agency, MT 59022
601
602
603
Crow Res.
Crow Agency
Lodge Grass
Pry or
1
1
1
3
7.
Dawson Co.
WIC Program
County Health Dept.
207 W. Bell
Glendive, MT 59330
111
131
281
551
Dawson Co.
Fallon C.
McCone Co.
Wibaux
1
1
1
1
4
8.
Deer Lodge Co.
WIC Program
121
Deer Lodge Co.
1
9#
Eastern Plains
WIC Program
Holy Rosary Hospital
2101 Clark St.
Miles City, MT 59301
091
171
381
401
441
Custer Co.
Garfield Co.
Powder River Cc
Prairie Co.
Rosebud Co.
1
1
). 1
1
1
5
Appendix 4
'
10. Flathead Co.
WIC Program
11. Flathead
Reservation
WIC Program
12. Fort Belknap
Reservation
WIC Program
723 5th Ave. E. 151
Kali spell, MT 59901
Flathead Tribal Health 611
Department
P. 0. Box 340
St. Ignatius, MT 59865
PHS Hospital 621
Ft. Belknap Hospital
R.R. #1, Box 103
Harlem, MT 59526
Flathead Co,
Flathead Res.
Fort Belknap Res. 1
13. Fort Peck
Reservation
WIC Program
14. Gallatin Co.
WIC Program
15. Glacier Co.
WIC Program
16. Granite Co.
WIC Program
17. Hill Co.
WIC Program
18. Lake Co.
WIC Program
19. Lewis and
Clark Co.
WIC Program
20. Lincoln Co.
WIC Program
21. Missoula Co,
WIC Program
WIC Proqram
P. 0. Box 729
Wolf Point, MT 59201
572
571
Fort Peck Res.
Wolf Point
Poplar
1
1
T
Rm. 105, Courthouse
Bozeman, MT 59715
161
341
Gallatin Co.
Park Co.
1
1
1
Glacier Co. Health Dept.
125 9th Ave., S.E.
Cut Bank, MT 59427
181
Glacier Co.
1
P. 0. Box 247
Philipsburg, MT 59858
201
Granite Co.
1
P. 0. Box 1466
Havre, MT 59501
211
031
261
Hill Co.
Blaine Co.
Liberty Co.
1
1
1
3
7 - 3rd Ave. W
Poison, MT 59860
241
Lake
1
Lewis & Clark Co.
316 North Park
Helena, MT 59623
251
222
221
Lewis & Clark Co.
Jefferson Co.
Boulder
Whitehall
1
1
1
3
P. 0. Box 873
Libby, MT 59923
271
272
Lincoln Co.
Libby
Eureka
1
1
2
Missoula City-County
Health Dept.
301 West Alder Street
Missoula, MT 59801
321
411
311
Missoula Co.
Ravalli Co.
Mineral Co.
1
1
1
3
Appendix 4
Page 2
22. Northern
Cheyenne
Reservation
WIC Program
23. Pondera Co.
WIC Program
24. Richland Co.
WIC Program
25. Rocky Boy
WIC Program
26. Sanders Co.
WIC Program
27. Silver Bow Co,
WIC Program
28. Stillwater Co.
WIC Program
29. Teton Co.
WIC Program
30. Valley Co.
WIC Program
621 2nd Street, S.
Glasgow, MT 59230
31. Yellowstone Co.
WIC Program
PHS Indian Health Center 581
Lame Deer, MT 59043
P. 0. Box 1291
Conrad, MT 59425
221 5th Street, S.W.
Sidney, MT 59270
PHS Indian Health Ctr.
Rocky Boy Route
Box 664
Box Elder, MT 59521
P. 0. Box 926
Thompson Falls, MT 59873
Family Service Center
25 West Front St.
Butte, MT 59701
350 West Pike
Columbus, MT 59019
P. 0. Box 820
Choteau, MT 59422
c/o Frances Mahon
Deaconess Hospital
Yellowstone City/County
Health Dept.
Room 205, Courthouse
Billings, MT 59101
371
421
631
Northern
Cheyenne Res,
Pondera Co.
Richland Co.
Rocky Boy Res
451
Sanders Co.
1
471
011
391
Silver Bow Co.
Beaverhead Co.
Powell Co.
1
1
1
I
481
Stillwater Co.
1
501
Teton Co.
1
531
361
Valley Co.
Phillips Co.
1
1
~7
561
562
051
Yellowstone Co.
Laurel
Lockwood
Heights
Carbon Co.
1
1
1
1
~1
TOTAL
56
Appendix 4
Page 3
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APPENDIX 4
Page 5
APPENDIX 5: CONDUCTING VENDOR INVESTIGATIONS
VENDOR MON HOPING
I. CONDUCTING THE INVESTIGATION
A. Procedures for Compliance Buys
Compliance staff should park their car away from the store so as not
to draw any attention to the car or persons in the car. Vendor
compliance staff should carry a camera and photograph the store. It
is helpful to include the compliance staff in the picture if possi-
ble, but it is not necessary. The photograph is useful in vendor
appeal hearings to establish that State investigators were at the
store and is also helpful for use by staff to remember the store and
what happened inside it. At times it may be necessary to park very
close to the store or have store personnel assist in taking the
items purchased to the car in order to avoid suspicion. It is
necessary to be sure that food from other buys or items such as
cameras or investigative reports are not left in view when this
occurs.
Appropriate dress for the area is also very important. Agents
should dress in casual clothes so as not to attract any undue
attention. Agents should not wear any clothing that would suggest
any affiliation with any religious or political group. In addition,
the agent should not carry any large sums of money (any money) with
them or wear any expensive jewelry. Clothes should not be so casual
as to indicate extreme poverty. At no time should the agents wear
any clothing or items that may be considered intimidating, such as
motorcycle gang jackets or knives.
Prior to actually entering the store, the agency should have an idea
of the nature of the neighborhood, and have established an idea of
where in the neighborhood they would purport to live or be residing.
It is best to be general in response to any questions asked by the
owner or clerk as to the residence, but one should always be able to
respond with street name or an apartment complex name to satisfy the
clerk or owner that they are from the neighborhood.
Upon entering the store, the agency should have in mind the type of
violation that will be attempted. The agent should first walk
through the store to assess the potential abuses and to confirm any
information that may have been reported to the State, i.e., low
stock, no WIC foods, etc. It is important to rely on the judgement
of the agent at the time he/she is in the store to determine exactly
that type of buy will take place. If it appears the store is low on
WIC foods nr does not carry some specific food categories, the agent
may wish to attempt to purchase a large variety of non-WIC eligible
foods as well as some non-food items. If the information available
to the agent is very limited and there appears to be an adequate
supply of WIC foods available, the agent may only attempt to pur-
chase items within the WIC food categories, but not specifically
approved for purchase with the voucher.
Appendix 5
Page 1
Observation of physical details is very important when in the store.
When the ..agent is filling out the report later, he/she will he asked
to recall "such details as the number of cash registers, a descrip-
tion of the clerk, including height and weight, hair and eye color,
and other physical factors (see Exhibit E for details). It is also
very helpful if the clerk can be identified by name. This helps to
determine later if the clerk is a regular employee or a temporary
employee who may not be trained.
When selecting which items to purchase with
important to follow these guidelines:
the vouchers it is
1. Never attempt to purchase any items that may cause the vendor
to feel any sympathy for the agent. Items that may give the
appearance that the person has a special need should not be
included. Such items may include band aids, medical supplies,
diapers, or childrens' toys at Christmas time.
2. It is best not to purchase any perishable items, as they may
need to be retained as evidence.
All items purchased .should have a price clearly marked on the
item and have some sort of size designation for packaged items.
If allowed to purchase
non-food items.
any items, it is best to mix food and
5. It is best to purchase a small number of expensive items rather
than a large number of inexpensive items.
6. Do not purchase items that could be confused with WIC items or
have similar brand names to WIC foods (i.e., Trix vs. Kix,
non-Iron Fortified Formula vs. Iron Fortified Formula, etc.).
When the items purchased are brought up to the cashier, the agent
should state that they will be using WIC vouchers to purchase the
items. At this point the agent should follow any instructions the
store personnel may give them with regard to the transaction. If
the clerk tells them they cannot buy the items, the agent should
return the items and pick up the correct ones. In some cases it is
appropriate to ask the clerk what items may be purchased. If the
clerk states that the agent may purchase additional items or more of
one item, the agent should do so. In some cases the store may have
a specific system they wish the agent to follow, and in this case,
the agents should follow the instructions as best they can. At
times the clerk may state that the agent should come back when the
manager or owner is there. If this is the case, the agent should
return the items and leave the store without purchasing any items.
Often agents will be asked a number of questions regarding their
status in the community or questions about their family. The agents
should provide as little information as possible, but should cooper-
ate to the best of their ability. Often this requires quick think-
ing on the part of the agent, but with experience this task becomes
easier. If asked questions about family members, the response
should not indicate in any way that a member of the family is sick
Appendix 5
Page 2
or in any special need. There are times that the agent may be asked <-
if he/she works for the state or government. When this occurs the
agent should indicate that he/she is not employed by the government,
and ask why they would inquire.
When the agent is making the purchase, he/she must be very careful
to avoid entrapment. Entrapment is defined as the influencing or
coercion on the part of an agent of another person to commit an
illegal act that he would not have normally committed in the absence
of such influence or coercion. It is important that the agent say
nothing that would try to influence or persuade the clerk to violate
the Guidelines. The agent may not make any statements related to
the consequence of the act such as "go ahead, nothing will happen to
you . "
When leaving the store it is best not to ask for any help with the
items. Upon return to the car the agent should mark the bag or box
with the store name so that the items may be photographed and
inventoried later. Any receipts or credit slips should be attached
to the Investigative Report and the physical description of the
store and clerk, as well as any comments of the clerk, should be
filled out. It is critical that the information be as complete and
accurate as possible. Agents must be sufficiently familiar with the
Investigative Report to be able to remember the types of information
they will be expected to recall.
It is the policy of the State to conduct at least two compliance
buys on a store that has violated the Program Guidelines. In some 4
cases it may be necessary to do many buys, as the level and degree
of non-compliance may change when the store personnel begin to
recognize the agent as a regular shopper. The policy of at least
two visits gives the agent a chance to determine if the store
personnel are trying to cheat the Program or they just don't under-
stand the Guidelines. In the latter case, the store may be more
deserving of a warning and training than a suspension.
Once the compliance buys have been completed and the food has been
inventoried and photographed, the items purchased are to be donated
to a charity in the area. Staff should have a listing of charities
in the areas so that the items purchased need not be brought back to
Helena. The agents shall fill out the Donated/Destroyed/Retained
Items Form for the charity to sign off. It is good policy for the
agent to ask the charity to send the State an acknowledgement letter
on agency letterhead to confirm that the items were actually left at
the charity.
B. Common Problems
The following are some of the problems that investigators have run
into during the course of making compliance buys. Frequently a
recommended solution must be adjusted to fit the occasion and
conditions at the time.
Problem 1: The store refuses to accept the vouchers for any
items, including WIC foods.
Appendix
Page 3
Recommended Solution: Leave the store and note this on
the report. An authorized vendor may be terminated for
not accepting vouchers.
Problem 2: The store personnel are hostile or threatening.
Recommended Solution: Leave the store. At no time have
agents doing compliance buys been threatened with harm,
but in case the agent believes that such a thing is
likely, they should leave the store and area as quickly as
possible. Such incidents should be reported and appropri-
ate action taken by the Program Supervisor.
Problem 3: The vendor wants you to return with your "wife,"
"husband," or "friend."
Recommended Solution: Explain that they are not avail-
able, and that you do not want to shop at a store that
would require you to do that every time. If they refuse
to allow you to purchase anything, leave the store.
Problem 4: The clerk states that they will only allow this to
occur at certain times or days.
Recommended Solution: Return at the time or day spec-
ified.
It is important to note that in most cases, there will be very few
problems encountered and the agent will be treated like the many
participants who use the store. Experience is the best solution for
handling problems, and agents will find they will feel very comfort-
able after doing buys over a period of time.
II. SANCTIONS AND FOLLOW-UP
A. The Investigative Report
After the compliance buy has been completed, the agent should
attempt to fill out as much of the Investigative Report as possible.
The agent may make any notes on the report that may be helpful in
recalling what went on in the store. Upon return to headquarters,
the Investigative Report should be typed and should only reflect the
facts of the buy. Opinions of a personal nature should not be
included in the report. The agent should submit the report to the
Program Supervisor for the case file, and should keep a copy of the
final typed report for reference.
B. Voucher Follow-Up
Often the store personnel will fill in the voucher after the agent
leaves the store or will alter the voucher if the agent fills it
out. It is critical that the vouchers used in the investigation be
retrieved after redemption and held as evidence. These redeemed
vouchers not only are evidence of the agent being in the sore and
the store accepting the vouchers, but also may show that an
Appendix 5
Page 4
overcharge occurred. All vouchers used in the buy should be com- /T"
pared with the report to be sure that the numbers and voucher type
match.
The Case File
Once a decision is made with regard to the disposition of the
market, a case file should be set up. The case file should be
divided into four s-ections. The first section should contain any
and all investigative materials that, will be used against the
vendor. These materials should include:
1. Any reports that were used to select the vendor for a compli-
ance buy.
2. Any complaints that were put in writing.
3. The Investigative Report or reports.
4. Any receipts or credit slips.
5. The vouchers used in the buy.
6. Any other relevant information to be used against the vendor,
such as prior warnings, vendor education visit documentation,
letters, etc.
The second section should contain the letter sent to the vendor with C
the charges contained and notifying the vendor of the selected
sanction. This section should also contain any other letters that
are sent to the vendor regarding the disposition of the case,
including any letters attempting to recover dollars or any offers of
reduced sanction or probation.
The third section should contain any correspondence from the vendor
regarding the matter. Phone contact by the vendor should be sum-
marized and made into- a file memo for this section.
The fourth section should contain any material related to an appeal.
This section will also contain the appeal decision when rendered.
Violations and Penalties:
The State must publish criteria used for sanctioning vendors. This
document must often be produced in appeal hearings to determine if
the penalty is consistent with the policy.
Vendor Recoveries and Probation
It is in the best interest of the State to recover dollars obtained
by a vendor in violation of the Federal Regulations whenever possi-
ble. Montana's policy is to recover funds when a clear overcharge is
discovered or there are documented loss levels established by the
investigation. Recovery of dollars may come in three forms.
1
C
Appendix 5
Page 5
s
First, the State may offer the vendor a reduced suspension on
condition that all dollars found to be obtained in violation of
Regulations be repaid. The vendor would then be required to make a
single payment to the State or repay the total amount over a period
of not more than ten months.
Second, the State may simply demand payment and hope the vendor will
repay the money. In any case, the vendor should not be allowed to
return to the Program until any claims are paid.
Third, the State may elect to take the vendor to court for dollars
obtained in violation of the Regulations. This would only be cost
effective if the claim were a large one.
F. Referrals
When it appears that a vendor or group of vendors are in violation
of more than just the WIC Program Guidelines, such as Food Stamp
Regulations, or Sanitation Laws, etc., the Program staff should
refer the case to the proper agency for their follow-up. Often the
agent will be asked to assist the referral agency in building a case
against the vendor, and such cooperation is beneficial to the WIC
Program.
III. APPEALS AND HEARINGS
A. Appeal and Hearing Procedures
Any vendor may appeal a decision of the Program staff to sanction
him by notifying the State within 15 days of receipt of the sanction
notice. The appeal letter should be addressed to the Health Services
and Hospital Facilities Division Administrator. The Division
Administrator may accept or deny the appeal based on the issues
raised in the letter. If the appeal is accepted, the Division
Administrator shall appoint a Hearing Officer who has no interest in
the WIC Program or the vendor. Appeal hearings shall be held in the
local agency's service area. In some rare cases vendor appeals may
be held in other areas if agreed to by the vendor and the- State.
The Hearing Officer shall conduct the hearing in accordance with the
policies set forth by the Department's Legal staff. The decision of
the Hearing Officer should be forthcoming within 60 days of the
close of the hearing record. No other administrative appeal proce-
dure is available to the vendor, but he may seek review in the
Supreme Court.
B. Hearing Schedules
It is important to hold the hearings as quickly as possible. The
person scheduling the hearings should not. accept delays unless
reasonable and necessary to assure fairness. The average length of
a hearing is between 40 minutes and 2 hours. Several hearings may
be scheduled on the same day to make the most efficient use of staff
time.
Appendix
Page 6
APPENDIX 6: PROGRAM BUY PACKET
VENDOR MONITORING
VOUCHER TRANSACTION REPORT
VENDOR NAME AND ADDRESS Vendor Number
Transaction Number
B. DATE OF VISIT
/ /
Mo. Day Year
AIDE'S STATEMENT
I, , declare:
On the above date at about (time) , I entered the
vendor's store. I had in my possession the WIC voucher(s) listed on page
3, Section E4 and no cash, as verified by ,
State Monitor. I selected the items listed in Section D. The vendor's
store has primary grocery check-out register(s); of
which was/were in operation at the time of purchase. At the check-out
counter where was/were person(s) in line ahead of me and
persons in the line behind me at the time of purchase. The clerk sold to
me the items listed in Section Dl, 2 and 3, at a total cost of $ .
During check-out the voucher(s) was/were in plain view of the clerk who
served me. I gave the cashier WIC vouchers. The clerk did/did
not give me a register tape for a total cost of $ .
KNOWN VIOLATIONS NOTED:
OTHER COMMENTS:
Appendix 6
Paae 1
SUMMARY OF PURCHASE
If Che voucher(s) were accepted,
complete the following:
A. Voucher //____
B. Total Price Charged $
Vendor Number
Transaction Number
D.l. Ineligible Items
Voucher
Number(s) Used
Quantity
Brand Name
Item
Purchase
Price
Shelf
Price*
Initials
D.2. Excessive Items
Voucher
Number (s) Used
Quantity
Brand Name
Item
Purchase
Price
Shelf
Price*
Initials
D.3. Eligible Items
Voucher
Number (s) Used
Quantity
Brand Name
Item
Purchase
Price
Shelf
Price*
Initial
D.4. Items C^erk Refused to Sell
Voucher
Number (s) Used
Quantity
Brand Name
Item
Purchase
Price
Shelf
Price*
Initials
D.5. Amount of Change or Cash Received, If Any $
*If Shelf Price is different than Purchase Price, explain how shelf price was obtained:
APPENDIX 6
PROGRAM BUY PACKET -- VENDOR MONITORING
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APPENDIX &
PROGRAM BUY PACKET -- VENDOR MONITORING
Pa?e 3
E.3. COMMENTS OF CLERK Continued:
APPENDIX 6
PROGRAM BUY PACKET -- VENDOR MONITORING
Page 4
Vendor Number
Transaction Number
a
Donated Items
I certify that I received from State Monitor
the ite
alongside which I have initialed in Sections Dl, D2 and D3 for use by my organization.
Signature
Title
Date
Organization
Address
Destroyed Items
I certify that I destroyed the items alongside which I have initialed because they
became unfit for human consumption or I was unable to donate them.
State Monitor
Witnessed By
Title
Date
?
Alcoholic Beverages
I certify that I destroyed the' alcoholic beverages alongside which I have initialed.
State Monitor
Witnessed By
Title
Date
Retained Items
I certify that I am retaining for evidence the items which are not initialed.
State Monitor
Date
Finding
The property item(s) donated, abandoned, or destroyed as certified in Sections Dl, D2
and D3 have been found to have no commercial value or the estimated cost of continued
care and handling would exceed the estimated proceeds from sale. Donation of item(s),
abandoned or destroyed was determined to be unfeasible. g
State Monitor
Date
APPENDIX 6
APPENDIX 7: VENDOR MONITORING CHECKLIST
VENDOR MONITORING
Voucher Numbers Recorded
Partial Completion of Vouchers
WIC Monitoring Forms
Cover Story
Possible Violations
Checkpoints (1 and 2)
Safety Precautions
Observations while in store (registers, clerks, etc.)
Make sure participant has no cash on person
. Drive directly to store and back to checkpoint
Appendix 7
Page 1
APPENDIX 8
VIOLATION SUMMARY
h
VENDOR'S NAME:
VENDOR'S ADDRESS:
VENDOR NUMBER:
VIOLATIONS NOTED:
MINOR :
Date
( / / )
Transaction
n
Date
( / / )
Transaction
#2
Date
( / / )
Transaction
in
Date
( / / )
Transaction
U
Date
( / /
Transacts
#5
Ineligible Items
— — — — — ^—
Excessive
Similar WIC Items
Other
■
MA.TOR:
— — — —
Cash
Rp.er
Liquor
■ ■
Laundrv Items
Fixed Amount on
Voucher (s)
-
Other
J
APPENDIX 8
VIOLATIONS SUMMARY — VENDOR MONITORING
Page 1
\
APPENDIX 9
LETTER FROM DHES ASSURING TITLE VI COMPLIANCE
May 31, 1987
TO WHOM IT MAY CONCERN:
The Montana Department of Health and Environmental Sciences certifies that it
will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88-35?) and in
accordance with Title VI of the Act, no person in the United States shall, on
the ground of race, color, or national origin, be excluded from participation
in, be denied the benefits of, or be otherwise subjected to discrimination under
any program or .activity for which the applicant receives Federal financial
assistance and will immediately take any measures necessary to effectuate this
agreement.
It will comply with Title VI of the Civil Rights Act of 1964 (42 USC 2000d)
prohibiting employment discrimination where (1) the primary source of a grant is
provide employment or (2) discriminatory employment practices will result in
unequal treatment of persons who are or should be benefiting from the
grant-aided activity.
Contracts and Grants Officer
Appendix 9
Page 1
APPENDIX 10
PROCEDURE FOR NOTICE TO THE GENERAL PUBLIC
FOR COMMENT ON STATE WIC PLAN
1. On the first Sunday in May of each year, the Montana WIC Program shall
publish in the Sunday edition of seven major newspapers in the state a
public notice requesting comment on the development of the state WIC plan
for the upcoming fiscal year.
2. This notice shall allow comments to be received in writing up to the close
of business on May 31.
3. Such comments should be addressed to the WIC Program Coordinator, Health
Services Division, Department of Health and Environmental Sciences,
Cogswell Building, Helena, Montana 59620.
4. The WIC Program Coordinator shall receive and review each written comment
and acknowledge receipt of same to the sender within 10 days of receipt.
5. WIC program Coordinator shall incorporate such comments as deemed
appropriate by the Coordinator.
6. A record of comments received and acknowledged shall be included as an
appendix in the final approved State WIC Plan.
7. The published notice for WIC comments shall include a statement to the
effect that copies of existing state plans are available at local WIC
offices or by contacting the WIC state program coordinator.
8. A final plan of state operations for the Montana WIC Program will be
submitted to the Director of DHES by the first Friday in June.
9. The plan approved by the Director of DHES shall be submitted to the
Governor's office by July 1.
10. The state WIC plan shall be transmitted to the USDA Regional Office in
Denver on or before August 15.
Appendix 10
Page 1
APPENDIX 11
NUTRITION EDUCATION (N.E.) EXPENDITURES: Nutrition Education Accounting System
Purpose: USDA WIC Regulations require us to account for 1/6 th (17%) of our
administrative monies to go towards nutrition education. Each local project and
the State staff have to account for the time and money they are spending on
nutrition education. To facilitate this, a simplified nutrition education
accounting system has been developed by the State Agency.
Who Completes: WIC Aide, Project Director, others that provide nutrition
education.
How Often: Minimum of once each federal fiscal year, usually during the month
of September.
Instructions: Please read the following instructions and study the forms
provided. During the month of September select 35 folders as per the instruc-
tions. The results are to be sent to the State Agency to be tallied. The State
Agency will provide the local agency with a report so that the local agency can
use this information in making up their nutrition education budget. (See
Nutrition Section of the Manual.)
Time Sheets A, B, C, and D must be completed and sent to the State Agency by the
10th of the following month.
Appendix 11
Page 1
GENERAL INSTRUCTIONS FOR NUTRITION EDUCATION (N.E.) ACCOUNTING SYSTEM
Please read the instructions thoroughly before beginning. Additional instruc-
tions are found on each form. This packet includes the following forms: Time
Sheet A, Time Sheet B, Time Sheet C, Sheet D, Definition of Nutrition Education
Costs, and this general instruction sheet. If any of these forms are missing,
notify the State Office before you begin.
1. Prior to the beginning of the month to be surveyed, randomly select,
according to the following instruction, 35 family folders from your
active files. Those projects that have satellite programs shall treat
each satellite as a separate project, pulling 35 folders from each
satellite or surveying all folders if the total number is less than 35.
Smaller projects with less than 35 active folders must also survey all
folders for that month.
a. Count the number of active family folders in your files.
b. Divide that number by 35. If there is a remainder, discard it.
c. Pull every _nth folder. (Example: 290 active family folders
divided by 35 equals 8. Pull every 8th folder from the file.)
2. Flag these files so they can be readily identified as the participants
come in for their appointments. Make a list of the files, assigning each
a sequential number. Record this number in plain sight on each -Pile.
Refile the folders.
3. When the first participant flagged comes into the project, distribute
Time Sheet A to each staff member. Each staff member will record under
the appropriate file number, the total number of participants in that
family. IMPORTANT: Be sure the total number of participants, NOT the
number each staff member sees is recorded.
Each staff member will then record the time they spent with the partici-
pants) in that family according to the details outlined in Time Sheet A.
If one staff member does not spend any time with that family that fits
into the definition, then a zero should be recorded for the number of
minutes spent.
4. As each flagged participant comes in during the month, repeat Step 3. To
avoid errors and inaccuracies, please record each activity as you com-
plete it. Remember only one Time Sheet A per staff member is to be used
for recording the time for all the files.
5. Record other personnel time not spent on direct client contact on Time
Sheet B as follows:
a. For the federal fiscal year (FFY), record for each staff member on a
separate Time Sheet B, activities that fall into the defined cat-
egories. Consult the Definition of Nutrition Education Costs
information for clarification. Record the average time spent per
activity on a monthly basis times the number of months of the FFY in
which the activity is performed.
Appendix 11
Page 2
b. IMPORTANT: Each staff member shall fill out Time Sheet B to record
expenditures and personnel time that may or may not occur each
month. For example, personnel time spent at a workshop, development
of the local nutrition education plan, CDC Nutrition Surveillance,
etc. Record time spent on evaluation and completion of care plans
which occur monthly on Time Sheet B also.
Record on Time Sheet C the N.E. materials and equipment ordered once or
twice a year and travel attributed to N.E.
At the end of the month selected, Project Director shall fill out Sheet C
— Nutrition Education Expenditure Report and Sheet D -- Summary Report.
Please fill out only those portions to be filled out by the local agency.
VERY IMPORTANT: Return Sheet C and Sheet D with filled out Time Sheet
B's and Time Sheet A ' s attached, to the State Office by the 10th of the
following month. The State Office will tally the results and return a
copy of Sheet D — Summary Report, for your records.
Appendix 11
Page 3
ALLOWABLE NUTRITION EDUCATION COSTS < I
For 1/6 Requirement
I. NUTRITION EDUCATION CONSULTATIONS
Time spent on nutrition education with the client (as individuals or
in groups). This includes, but is not limited to, explanations of
the food package, explanations of assessment criteria (but not
actual assessment), going over handouts, discussing progress and
improvement, and evaluation and development of the care plan.
Time spent by staff preparing and teaching well child clinics,
prenatal classes, and other nutrition education programs, for WIC
clients.
The mailing of nutrition education materials to participants as part
of nutrition education consultations.
Travel time expenses to consult with satellite on nutrition educa-
tion.
II. NUTRITION EDUCATION MATERIALS
(This includes, but is not limited to, handouts, flip charts, film
strips, projectors, food models, and other teaching helps.)
Time spend processing or developing nutrition education materials.
Equipment specifically used for nutrition education.
Any costs incurred through purchasing nutrition education materials
from other sources.
Any costs incurred (i.e., materials, copying costs, postage, etc.).
III. NUTRITION EDUCATION TRAINING
Time spent developing training programs.
Time spent attending nutrition education training.
Any costs incurred (i.e., materials, copying costs, postage, etc.).
Any equipment specifically used for nutrition education training.
Travel time expenses for workshop devoted to nutrition education.
IV. NUTRITION EDUCATION EVALUATIONS
Time spend developing and implementing nutrition education eval-
uations. (Evaluations include, but aren't limited to, participant
evaluation of nutrition education, CDC-Nutrition Surveillance, and
the design of data collection forms and compilation and analysis of
data.)
Appendix 11
Page 4
Any other costs incurred (i.e., materials, copying costs, postage,
etc. ) .
V. LOCAL NUTRITION EDUCATION PLANS
Time spent developing the local nutrition education plan.
Any other costs incurred (i.e., materials, copying costs, postage,
etc.) .
VI. MONITORING NUTRITION EDUCATION
Local staff's time spent on state nutrition education monitors.
Time spent on self-monitoring nutrition education.
Any other costs incurred (i.e., materials, copying, costs, postage,
etc.) .
These proposed guidelines are not all-inclusive, and any other nutrition
education costs that can be justified may be allowed.
Appendix 11
Page 5
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Appendix 11
Page 6
TIME SHEET B
INDIVIDUAL TIME SHEET/ NUTRITION EDUCATION
Instructions: Fill out one for each staff member per project and/or satellite.
Period covered: From 10/1/8 to 9/30/8 Project Name and Location
Position Salary /Hour
ACTIVITY
Hours
Per Month
(Nearest \ hr)
X
Number of Months
Activity is per-
formed: i-ir1
Total Hours
= Per Year
EVALUATION AND DEVELOPMENT OF CARE PLANS
PREPARING & TEACHING NUTRITION EDUCATION PRO-
GRAMS FOR WIC PARTICIPANTS (i.e., well-child
clinics, prenatal classes, etc.)
PREPARING, UPDATING, REVIEWING, OR SELECTING
NUTRITION EDUCATION MATERIALS
DEVELOPING TRAINING PROGRAMS DEALING WITH
NUTRITION EDUCATION
ATTENDING NUTRITION EDUCATION TRAINING
SESSIONS (either State, Regional, or
in-service)
CDC - NUTRITION SURVEILLANCE
PARTICIPANT EVALUATION OF NUTRITION EDUCATION
DEVELOPING THE LOCAL NUTRITION EDUCATION PLAN
NUTRITION EDUCATION SELF-MONITORING (count only
that time spent on nutrition, not the whole
monitor )
NUTRITION EDUCATION STATE MONITORING
■,'•. -J
TIME SPENT ON THIS NUTRITION EDUCATION ACCOUNT-
ING SYSTEM
THER (Please specify)
i
TOTAL
Signature of Staff Member:
Today's Date:
Appendix 11
Paae 7
SHEET C - NUTRITION EDUCATION EXPENDITURE REPORT ^
INSTRUCTIONS: Fill out only for non--oersonnel expenditures. Do not fill out State Of'-'ce
Portion. See Definition of Nutrition Education Cost sheet for clarifi^ ic
NAME OF AGENCY: (fill cut one for each satellite or project)
PERIOD: From October 1, 198 to September 30, 198 .
OBJECT CLASS CATEGORY
CURRENT NUTRTTTONAI, KPUCA'I' LON
EXPENDITURES
1. Personnel (STATE OFFICE WILL FILL OUT)
2. Fringe Benefits (STATE OFFICE WILL FILL OUT)
"
3- Equipment & Supplies (Purchased
List Items
for Nutrition Education during
this Federal Fiscal Year,
Oct. 1, 198 to Sept. 30, 198
k. Travel (partially attributed to N.E. from
Oct. 1, 198 to Sept. 30, 198 )
(Exclude State-sponsored workshops )
5. Other (Please List)
K
TOTAL
APPENDIX 11
NUTRITION EDUCATION ACCOUNTING SYSTEM
irt 8
■3
2.
3-
k.
5.
6.
Project Name_
SHEET D - SUMMARY SHEET
(list satellite operations separately)
SIGNATURE OF PROJECT DIRECTOR:
Date Survey Covered: October 1, 198 to September 30, 198 .
Active Caseload (Actually receiving drafts in Sep) (satellites listed separately)
Total number of folders surveyed (should agree with Time Sheet A)
Total number of participants surveyed (should agree with Time Sheet A)
Total number of Time Sheet A's attached ; D's ; C'i
FOR STATE OFFICE USE ONLY
DATE:
Signature-State Agency Official
7. Summary of Time Sheet A's:
Total Minutes Wage/
Staff Position Per Position Hour
Total
Participants
Monthly
Caseload x 12 mo $ Subtotal
60 minutes
Total :
Summary of Time Sheet B's:
Staff Position Time in Hours
Wage /Hour
$ Subtotal
• -• Total:
9. Transfer totals from 7 and 8 to Sheet C - Nutrition Education Expenditure Report by
project and/or satellite.
10. Yearly total from Time Sheet C =
11. % of administrative expenditure for year =
Revised 8/82
APPENDIX 11 '
NUTRITION EDUCATION ACCOUNTING SYSTEM
WIC NUTRITION EDUCATION
PARTICIPANT SURVEY
We need your help! As you know, the WIC program provides both nutrition educa-
tion and supplemental foods to its participants -- We would like to know how we
can make our program more effective. Please help us by answering the following
questions. There are no right or wrong answers. If you need help, please ask a
staff member for assistance.. Your answers will not be reviewed at this clinic
and ail responses will be kept confidential.
After completing this form, place it in the envelope provided. Please do not
put your name on this questionnaire. Answering these questions will not affect
your WIC eligibility or benefits.
1) Please check (X) which of the following members of your family are on the
WIC program now:
Pregnant Woman Pregnant Teen (17 years or younger)
Breastfeeding Woman Breastfeeding Teen (17 yrs or younger)
Infant (0-12 months) Child (13 months - 5 years)
2) I feel learning about nutrition is: (X) Check the best answer below:
1. Very important /»
2. Somewhat important
3. Not important
3) The nutrition information and care I have received at WIC has been: (X)
Check the best answer below:
1. Very helpful
2. Somewhat helpful
3. Slightly helpful
4. Not helpful
5. I receive no nutrition information at WIC
4) I like to learn about nutrition from: (X) Check your answer(s) below:
1. Nutrition information given in a group setting - Classes
* 2. Movies, film strips, slides or video programs about nutrition
3. Pamphlets for me to read
4. Posters and bulletin boards in the clinic
5. The WIC professionals talking to me alone in a private setting
about nutrition
6. Please add your own suggestions:
APPENDIX 12
Page 1
5) Do you find the individual nutrition counseling you receive at WIC helpful?
(X) Check the best answer below:
1. ^ery helpful
2. Somewhat helpful
3. Slightly helpful
4. Not helpful
5. I receive no individual nutrition counseling at WIC
6) Has the WIC program been helpful to you in getting your nutrition questions
answered? (X) Check the best answer below:
1. Very helpful
2. Somewhat helpful
3. Slightly helpful
4. Not helpful
5. They have not answered my nutrition questions
7) Do you feel the recommendations/suggestions made by the WIC staff help you
with your health problems? (X) Check the best answer below:
1. Very helpful
2. Somewhat helpful
3. Slightly helpful
4. Not helpful
5. No recommendations/suggestions have been made
What do you do with nutrition pamphlets given to you at the WIC clinic?
(X) Check your answer(s) below:
1. I throw them away
2. I read them
3. I share them with family/friends
4. I put them away without reading them
5. I have not received any pamphlets on nutrition
6. I do not want to receive any pamphlets on nutrition
7. Other (please explain)
9) What do you think about the pamphlets? (X) check your answer(s) below:
1. I read them but they do not help
2. They are helpful when given with an explanation
3. I don't read them
4. I like it when they include recipes
5. They help a little
6. They are very helpful
7. I don't receive any pamphlets on nutrition
APPENDIX 12
Page 2
10) Please (X) check the nutrition topics below that you would like to learn
more about:
(V
General Nutrition
Infant Nutrition
1.
How nutrition relates
2.
to health
Exercise and nutrition
3.
Gaining weight
4.
Losing weight and
5.
weight control
Foods that help build
6.
good blood
Good Snacks
7.
Fast foods
8.
How to use MIC food
9.
drafts
How to read food labels
10.
11.
How to save money on
foods
Recipes using WIC
foods
Child Nutrition
15.
16.
17.
18.
19..
20.
Baby Bottle Tooth Decay
Feeding my baby
Weaning my baby
How to prepare baby formula
How do I know if my in-
fant is getting enough
breast mil k?
How much formula does my
infant need
Maternal Nutrition
when
12. Dental care and healthy
teeth
13. Feeding my toddler
14. Feeding the picky
eater
21. Foods needed
pregnant
22. Breastfeeding
23. Nutrition and Birth
Control
24. Alcohol, tobacco or drug
use during pregnancy
*
25. Other nutrition information I would like (add your suggestions)
11) I feel the WIC staff could be more helpful to me if they: (X) Check the
ideas below:
1. Explained nutrition in words I can understand
2. Offered more classes (group sessions)
3. Offered less classes (group sessions)
4. Tell me when classes will be held
5. Offered appointments and classes in the evening
6. Gave nutrition information while I'm waiting for my appointment
7. Offered more individual counseling on nutrition and diet
8. Other suggestions
APPENDIX
Page 3
12
12) Please (X) check any of the following statements that you agree with:
1. The staff understands my culture and family background
2. The suggestions for changes are within my budget
3. The suggestions for changes in my diet are foods my family
would eat.
4. The suggestions for changes in my diet are clear and simple
to do
5. The suggested recipes use ingredients which I have at home
6. Comments
13) Has the WIC program helped you to improve the kind of food you and your
family eat? (X) Check your answer below:
1. Yes 2. No
14) WIC has helped my family the most by: (X) check the best answer below:
1. Giving us nutritious foods
2. Giving us information on nutrition
3. Giving us both nutritious foods and nutrition information
4. WIC has not been of much help to my family
5. Other comments
15) (X) Check any of the following which describe you and your family's eating
habits now, compared to when you weren't on WIC:
1. We eat the same
2. We eat better and spend the same amount of money on food
3. We eat better and spend less money on food
4. Other comments
16) How can we improve the WIC program?
THANK YOU FOR YOUR HELP!
SS/vb-lOlb
APPENDIX 12
Page 4
APPENDIX 13: MODEL AGREEMENT
AGREEMENT
An Agreement is hereby made between ^__ (County) and the
Montana Department of Health and Environmental Sciences (DHES). The parties, in
consideration of mutual covenants and stipulations described below, agree as
follows:
SECTION I PURPOSE
The purpose of this Agreement is to provide the services of the USDA's Special
Supplemental Food Program for Women, Infants and Children (WIC) to residents of
County.
SECTION II: SERVICES
A. The County shall, to the extent that the funding stated in Section IV
allows, do the following during the period from July 1, 198 through June 30,
198 :
(1) Conduct the Special Supplemental Food Program for Women, Infants and
Children (WIC) by assuming all administrative, financial and professional health
service responsibilities for the WIC Program within County.
The County shall administer the WIC Program in accordance with the
current regulations contained in 7 CFR Part 246; the 1985 WIC State Plan; U.S.
Food and Nutrition Service (FNS) guidelines and instructions; and the WIC
Policies and Procedures Manual, as revised August, 1981, and updated thereafter.
(2) Provide performance, activity, and fiscal reports required by DHES,
including, but not limited to, the following:
(a) time distribution records for employees. Such records need not
be submitted to DHES in Helena, but shall be kept available at the main
office of the County for audit purposes, to be checked during regular
monitoring visits conducted by staff of DHES or independent auditors.
(b) itemized expenditure reports. The County shall submit these
reports to DHES by the 15th of each month, beginning with August, 1984,
unless DHES agrees there is a good cause for the delay (e.g., a differ-
ence between the monthly close-out dates of the WIC Program and the
County). Any adjustment to an expenditure report will be eligible for
reimbursement only if it is received by DHES prior to the end of the
calendar month following the month for which the adjusted expenditure
report is claimed.
(3) Maintain complete, accurate, documented, and current accounting of
all program funds received and expended.
(4) Ensure that no claim is submitted for reimbursement of services
already funded by other state or federal programs, or for costs which are not
allowable under 7 CFR 246.14.
(5) Obtain written prior approval from DHES before, and as a condition
of, purchasing equipment costing more than $200.00 with WIC funds. If such
approval is given by DHES and the equipment is purchased, it is the property of
DHES.
(6) Assume responsibility for the safe storage of negotiable food
vouchers and reimburse DHES for any WIC Program funds misused or otherwise
Appendix 13
Page 1
diverted due to negligence, fraud, theft, embezzlement, or other loss caused by
the County, its employees, or agents.
(7) Contract with food vendors and follow procedures for issuance of
food vouchers to WIC participants in conformity with 7 CFR Sections 2^6.12 and
Section VIII of the Policies and Procedures Manual cited in paragraph 1 above.
(8) Employ for the WIC program one of the following types of individuals
to perform duties of certification, prescription of WIC foods, counseling of
high risk clients, nutrition education, and planning of nutrition services to be
delivered under the program, in conformity with 7 CFR Section 246.7, 246.10, and
246.11, FNS guidelines and instructions, and the 1986 WIC State Plan: a
physician, nutritionist (with a bachelor's or master's degree in nuitritional
sciences, community or clinical nutrition, dietetics, public health nutrition,
or home economics with emphasis in nutrition), dietitian, registered nurse,
physician's assistant certified by the National Committee on Certification of
Physician's Assistants or the Montana Board of Medical Examiners, or a state or
local medically trained health official.
(9) Abide by the nutritional health plan developed by the County for FY
1986 in accordance with 7 CFR Section. 246.11 (d)(2) and the 1986 WIC State Plan
and submitted to DHES.
(10) Ensure that one-sixth (l/6th) of the reimbursement claimed by the
County each month is for time spent by personnel in nutrition education of WIC
clients in compliance with 7 CFR Section 246.11 and the 1986 WIC State Plan.
(11) Assure that one staff person involved in the WIC Program attends
regularly scheduled workshops sponsored by DHES on administrative policies,
procedures, and nutrition. Other personnel deemed appropriate by the County may
attend subject to availability of funding from DHES. In the event that inclem-
ent weather intervenes, attendance at such workshops will not be mandatory.
(12) Make available to all WIC participants ongoing health services as
outlined in 7 CFR Sections 246.2 and 246.6 (b)(3) and Section V of the Policies
and Procedures Manual cited in paragraph 1 above, and inform applicants of the
health services which are available.
(13) By July 15, 198 , submit to DHES for approval a draft contract with
each satellite county listed in paragraph (1) above (if any) defining the
respective responsibilities for the WIC Program of the satellite and the County,
and provide DHES with a copy of each such contract, after execution of it,,
within two months after receipt of written approval from DHES.
(14) Comply with all requirements imposed by the U.S. Department of
Agriculture concerning administrative requirements approved in accordance with
Office of Management and Budget Circular No. A-102 and A-87, including those
relating to procurement of supplies, equipment and other services, as well as
the utilization and disposition of property purchased in whole or in part with
WIC funds.
(15) Keep on file and available for review, audit and evaluation:
(a) a copy of this Agreement;
(b) information on the character of the service area and financial
eligibility standards used;
(c) complete and accurate written records of nutritional assessment
criteria, criteria for certification of applicants, foods prescribed,
nutrition care, counseling, education and referrals provided under the
WIC Proqram;
(d) complete, accurate, documented and current accounting of all
funds received pursuant to this Agreement and expended.
Appendix 13
Page 2
B. DHES shall
(1) Provide a minimum of one regularly scheduled workshop annually for
project personnel for training in administrative policies, procedures, and
nutrition services as referenced in Part A above.
(2) Pay travel expenses for the staff person attending the workshops
required by part A, paragraph (11), above. Such travel expenses shall be
reimbursed at the rates set for in-state travel of state employees in Title 2,
Chapter 18, Part 5, Montana Code Annotated, or at a rate agreed upon by the
County and DHES.
(3) Send staff to visit and monitor the County's WIC Program in order to
determine compliance with administrative and nutrition service requirements of
this Agreement.
SECTION III: EFFECTIVE DATE AND DATE TO COMPLETE SERVICES
This Agreement shall take effect as of July 1, 198 , and the services provided
pursuant to Section IA must be continued through June 30, 198 , unless this
Agreement is terminated earlier pursuant to Sections V or X.
SECTION IV: CONSIDERATION
In consideration of services rendered pursuant to this Agreement, DHES agrees to
reimburse the County for the following:
(1) salaries and fringe benefits for personnel while engaged in perfor-
mance of this Agreement, at the rate of l/12th (8.3%) per month of the funds
allocated for personnel services in the Attachment A budget; DHES will reimburse
for expenditures in excess of this amount only if it has approved the excess
expenditure before it was accrued.
(2) indirect costs (at the rate of 5%), and any other expenses necessary
and related to administration of the WIC Program by the County, considered
allowable by 7 CFR 246.12, and listed in the budget in Attachment A; expendi-
tures in any budget category (except salaries and benefits) may not exceed 10%
of that category unless DHES gives its approval in advance.
As soon as possible after execution of this Agreement, DHES shall pay the County
an advance of $ .
Subject to the receipt of funds from U.S.D.A., DHES shall reimburse the County
for services performed under this Agreement upon DHES' receipt from the County
of completed and signed expenditure reports, within the time limit set in
paragraph A (2)(b) of Section II, and a signed vendor invoice request for funds.
Reimbursable expenditures for the period from July 1, 198 , through September
30, 198 , must not exceed $ .
A final statement of all outstanding reimbursable expenses must be submitted by
July 31, 198 , if they are to qualify for payment. If the total amount paid
under this Agreement exceeds all reimbursable expenses once the services under
this Agreement have been completed, the balance will be returned to DHES. Total
payments by DHES for all purposes under this Agreement shall not exceed
$
Appendix 13
Page 3
SECTION V: TERMINATION
(1) The County understands and agrees that DHES, as a state agency, is
dependent upon federal and state appropriations for its funding, and that
actions by Congress, U.S.D.A., or the Montana Legislature may preclude funding
this Agreement through the completion date stated in Section III. Should such a
contingency occur, the parties agree that DHES may set a new completion date or
terminate the contract immediately, depending upon the funding remaining avail-
able for the Agreement, and that the County will be compensated for services
rendered and expenses incurred to 5:00 p.m. of the revised completion date.
(2) In addition to the provisions of paragraph 1 above, and Section X,
either party may terminate this Agreement for failure of the other party to
perform any of the services, duties, or conditions contained in this Agreement
after giving 30 days written notice to the other party.
(3) Any termination of this Agreement is subject to the exception that
paragraph (4) of Section X, relating to retention of and access to records, will
remain in effect.
SECTION VI: ASSIGNMENT AND SUBCONTRACTING
The parties agree there will be no assignment or transfer of this Agreement, or
of any interest in this Agreement, unless both parties agree in writing. The
parties agree that no services required under this Agreement may be performed
under subcontract unless both parties agree in writing.
SECTION VII: EQUAL OPPORTUNITY
The County agrees that it will comply with Title VI of the Civil Rights Act of
1964 (P.L. 88-352) and all requirements imposed by the regulations of the
Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts
42 and 50) and Food and Nutrition Service directives or regulations issued
pursuant to that Act and its regulations, to the effect that no person in the
United States shall, on the ground of race, color, national origin, age, sex, or
handicap, be excluded from participation in, be denied the benefits of, or be
otherwise subject to discrimination under any program or activity for which the
County received federal financial assistance from the Department; and hereby
gives assurance that it will immediately take any measures necessary to effect-
uate this Agreement.
This assurance is given in consideration of an for the purpose of obtaining any
and all federal financial assistance, grants and loans of federal funds, reim-
bursable expenditures, grant or donation or federal property and interest in
property, the detail of federal personnel, the property or interest in such
property of the furnishing of services without consideration or at a nominal
consideration, or at a consideration which is reduced for the purpose of assist-
ing the recipient, or in recognition of the public interest to be served by such
sale, lease, or furnishing of services to the recipient, or any improvements
made with federal financial assistance extended to the County by DHES. This
includes any federal agreement, arrangement, or other contract which has as one
of its purposes the provision of assistance such as food, and cash assistance
for purchase or rental of food service equipment or any other financial assis-
tance extended in reliance on the representations and agreements made in this
contract.
Appendix 13
Page 4
By accepting this assurance, the County agrees to comDile data, maintain records
and submit reports as required, to permit effective enforcement cf Title VI and
to permit authorized U.S.D.A. personnel during normal working hours to review
such records, books and accounts as needed to ascertain compliance with Title
VI. If there are any violations of this assurance, the Department of Agricul-
ture, Food and Nutrition Service, shall have the right to seek judicial enforce-
ment of this assurance. This assurance is binding on the County, its succes-
sors, transferees, and assignees as long as it receives assistance or retains
possession of any assistance from DHES. The person or persons whose signatures
appear below are authorized to sign this assurance on behalf of the program
appl icant.
In addition, pursuant to Sections 49-2-303 and 49-3-207 of the Montana Code
Annotated, no part of this contract shall be performed in a manner which dis-
criminates against any person on the basis of race, color, religion, creed,
political ideas, sex, age, marital status, physical or mental handicap, or
national origin by the persons performing the contract. Any hiring shall be on
the basis of merit and Qualifications directly related to the requirements of
the particular position being filled.
SECTION VIII: VENUE
The parties agree that, in the event of litigation concerning this Agreement,
the venue shall be in the First Judicial District of the State of Montana, in
and for the County of Lewis and Clark.
SECTION IX: MODIFICATIONS AND PREVIOUS AGREEMENTS
This instrument contains the entire Agreement between the parties, and no
previous statements, promises, or inducements made by either party or agent of
either party which are not contained in this written Agreement shall be valid or
binding. This agreement may not be enlarged, modified, or altered except in
writing, signed by the parties. No change, addition, or erasure of any printed
portion of this Agreement shall be valid or binding upon either party.
SECTION X: AUDITING, RECORD RETENTION, AND ACCESS TO RECORDS
(1) The County agrees to allow access to the records of the activities
covered by this Agreement as may be necessary for legislative audit and analysis
purposes in determining compliance with the terms of this Agreement, as required
by Section 5-13-304, Montana Code Annotated. Notwithstanding the provisions of
Section V, this Agreement may be terminated upon any refusal of the County to
allow access to records necessary to carry out the audit and analysis referred
to above.
(2) The County must provide DHES by September 30, 1986, with a copy of
an agency audit covering the time period stated in Section III and complying
with the audit requirements of the federal Office of Management and Budget's
(0MB) Circular A-102, Attachment P.
(3) The State of Montana, DHES, the U.S. Department of Agriculture, Food
and Nutrition Service, the Comptroller General of the United State, and the
General Accounting Office of the United States, or any of their duly authorized
representative, have the right of access to any books, documents, papers, and
records of the County which are pertinent to the services provided under this
contract, for purposes of making an audit, excerpts, or transcripts. Further,
for purposes of verifying cost or pricing data submitted in conjunction with the
negotiation of this contract or any amendments thereto, the State and DHES,
Appendix 13
Page 5
until the completion date cited in Section III, have the right to examine those
books, records, documents, papers, and other supporting data which involve
transactions related to this Agreement or which will permit adequate evaluation
of the cost or pricing data submitted, along with the computations and projec-
tions used for them.
(4) Financial records, supporting documents, statistical records, and
all other records documenting the services provided by the County under this
Agreement must be retained for a period of 3 years after the date of submission
of the final statement of reimbursable expenses referred to in Section IV. The
County agrees to make the records described herein available at all reasonable
times at its general offices. If any litigation, claim, or audit is started
before the expiration of the 3-year period, the records must be retained until
all litigation, claims, or audit findings involving the records have been
resolved. The County, whenever it is ready to dispose of the above records,
will submit them to the Food and Nutrition Service if that agency has requested
them.
SECTION XI: SEVERABILITY
It is understood and agreed by the parties hereto that if any term or provision
of this contract is by the courts held to be illegal or in conflict with any
Montana law, the validity of the remaining terms and provisions shall not be
affected, and the rights and obligations of the parties shall be construed and
enforced as if the contract did not contain the particular term or provision
held to be invalid.
SECTION XII: LIAISONS
The County's liaison to DHES for purposes of this Agreement is the following
person, or that person's successor.
Name Title
DHES' liaison to the County for purposes of this Agreement is David Thomas, or
his successor.
SECTION XIII: EXECUTION
This Agreement consists of 8 pages and one attachment. The original is to be
retained by the Financial Management Division of DHES. A copy of the original
has the same force and effect for all purposes as the original.
Appendix 13
Page 6
To express the parties' intent to be bound by the terms of this Agreement, they
have executed this document on the dates set out below:
Date
By:
COUI
m
Signature
Print Name
Address
and
Ti
tie
>
MT
Employer' s
ID
No.
Approved for legal content by:
DEPARTMENT OF HEALTH AND
ENVIRONMENTAL SCIENCES
Date
BY:
Robert L. Solomon
Contracts Officer
Eleanor A. Parker
Date
Appendix 13
Page 7
ATTACHMENT
A
AGENCY:
FTE's Competent Profes
Nutrition Aide
TOTAL
sional Auth
ority
Salaries
Benefits
Indirect
Travel
Equipment
Supplies
Rent
Telephone
OPERATING EXPENSES
Postage
Utilities
Services
Repairs
Contracted
Nutrition Education
Other
TOTAL
July 1, 1985 - Septembe
r 30, 1985
October 1, 1985 - June
30, 1986
Appendix 13
Page 8
APPENDIX 14:
MODEL SATELLITE AGREEMENT: WIC PROGRAM:
A cooperative agreement is hereby made between (hereinafter
referred to as "Satellite") and the (hereinafter
referred to as "Local Agency"), in order to extend to County
the services of the. Women. ^ Infants and Children (WIC) ...Program, for which Local
Provider is responsible under separate contract with the Montana Department of
Health and Environmental Sciences (DHES). The parties, in consideration of
mutal covenants and stipulations described below, agree as follows:
SECTION I: SERVICES
A. The Local Agency agrees to perform the following services:
(1)
(2)
(3)
etc.
B. The Satellite agrees to perform the following services:
(1) Maintain a complete, accurate, documented, and current accounting of
WIC Program funds received from Local Agency.
(2)
(3)
etc.
(NOTE: Each party's respective duties for the WIC Program should be carefully
described above. Examples of duties are listed below; these and any other
duties should be listed under either A or B above, depending upon which agency
assumes the responsibility:)
(1) Maintain whatever WIC performance, activity and fiscal reports are
required by DHES, including, but not limited to the following:
(a) Time distribution records for employees;
(b) Itemized monthly expenditure reports. (If the Satellite keeps
these reports, the agreement must include a requirement that
the Satellite submit a copy to the Local Provider by the 10th
day of each month following the month to which the report
relates. )
(2) Maintain careful records for each WIC client.
(3) Issue food vouchers to WIC participants in conformity with 7 CFR,
Sections 246.10 and 246.11.
Appendix 14
Page 1
(4) Employ or contract for a registered dietitian or other person whose
qualifications are approved by the Montana Department of Health and
Environmental Sciences (DHES) to perform duties of certification,
prescription of WIC foods, counseling of high risk clients, and
planning nutrition services to be delivered under the program, in
conformity with 7 CFR Sections 246.6 through 246.9 and the 1984 WIC
State Plan of DHES.
(5) Employ or contract for program assistants as necessary to carry out
clerical duties such as making client appointments, issuing drafts,
and preparing reports.
(6) Provide space for program operations, specifically interviews,
storaqe for materials and supplies, and utilization of educational
aids (projectors, tape players, etc.).
(7) Make available to all WIC participants ongoinq health services as
outlined in 7 CFR Sections 246.2 and 246.6(b)(3) and Section II-A of
DHES' most current WIC Policies and Procedures Manual, and as
specified by DHES' Nursing Bureau.
SECTION II: EFFECTIVE DATE AND DATE TO COMPLETE SERVICES
This Agreement shall take effect as of , and the services required
by Section I shall continue through (date), unless this
Agreement is terminated earlier pursuant to Sections IV.
SECTION III: CONSIDERATION
In consideration of services rendered pursuant to this Agreement, and subject to
receipt of funds from DHES, the Local Agency shall pay for those items which
were necessary to the Satellite's performance of this Agreement and are speci-
fied in Appendix A of this Agreement, subject to receipt from the Satellite of
completed and signed expenditure reports (required by Section 1(B)(7)). Total
payments for Satellite's services under this Agreement will not exceed
$ .
A final statement of all reimbursable expenses must be submitted within 30 days
after the latest date cited in Section II if they are to qualify for payment.
SECTION IV: TERMINATION
(1) Satellite understands and agrees that since funding for this Agreement is
available through a contract by Local Provider with DHES, a state agency which
is dependent upon federal and state appropriations for its funding, actions by
Congress or the Montana Legislature may preclude funding this Agreement com-
pletely through the completion date stated in Section II. Should such a contin-
gency occur, the parties agree that the Local Agency may set a new completion
date or terminate the contract immediately, depending upon the funding remaining
available for the Agreement, and that the Satellite will be compensated for
services rendered and expenses incurred to 5:00 p.m. of the revised termination
date.
(2) In addition to the provisions of paragraph (1) above and Section IX,
either party may terminate this Agreement for failure of the other party to
Appendix 14
Page 2
perform any of the services, duties, or conditions contained in this Agreement
after giving 30 days written notice to the other party.
(3) Any termination of this Agreement is subject to the exception that
paragraph (2) of Section VII, relating to retention of and access to records,
will remain in effect.
SECTION V: EQUAL OPPORTUNITY
The Satellite agrees that it will comply with Title VI of the Civil Rights Act
of 1964 (P.L. 88-352) and all requirements imposed by the regulations of the
Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR Parts
42 and 50) and Food and Nutrition Services directives or regulations issued
pursuant to that Act and its regulations, to the effect that no person in the
United States shall, on the ground of race, color, national origin, age, sex or
handicap, be excluded from participation in, be denied the benefits of, or be
otherwise subject to discrimination under any program or activity for which the
Satellite receives federal financial assistance from the Local Agency; and
hereby gives assurance that it will immediately take any measures necessary to
effectuate this agreement.
This assurance is given in consideration of and for the purpose of obtaining any
and all federal financial assistance, grants, and loans of federal funds,
reimbursable expenditures, grant or condition of federal property and interest
in property, the detail of federal personnel, the sale and lease of, and permis-
sion to use, federal property or interest in such property or the furnishing of
services without consideration or at a nominal consideration, or at a consid-
eration which is reduced for the purpose of assisting the recipient, or in
recognition of the public interest to be served by such sale, lease, or furnish-
ing of services to the recipient, or any improvements made with federal finan-
cial assistance extended to the Satellite by the Local Agency. This includes
any federal agreement, arrangement, or other contract which has as one of its
purposes the provision of assistance such as food, and cash assistance extended
in reliance on the representations and agreement made in this assurance.
By accepting this assurance, the Satellite agrees to compile data, maintain
records and submit reports as required, to permit effective enforcement of Title
VI and to permit authorized U.S.D.A. personnel during normal working hours to
review such records, books and accounts as needed to ascertain compliance with
Title VI. If there are any violations of this assurance, the Department of
Agriculture, Food and Nutrition Service, shall have the right to seek judicial
enforcement of this assurance. This assurance is binding on the County, its
successors, transferees, and assignees as long as it receives assistance or
retains possession of any assistance from the Local Agency. The person or
persons whose signatures appear below are authorized to sign this assurance on
behalf of the Satellite.
In addition, pursuant to Sections 49-2-303 and 49-3-207 of the Montana Code
Annotated, no part of this contract shall be performed in a manner which dis-
criminates against any person on the basis of race, color, religion, creed,
political ideas, sex, age, marital status, physical or mental handicap, or
national origin by the persons performing the contract. Any hiring shall be on
the basis of merit and qualifications directly related to the requirements of
the particular position being filled.
Appendix 14
Page 3
SECTION VI: MODIFICATIONS AND PREVIOUS AGREEMENTS
This instrument contains the entire Agreement between the parties, and no
previous statements, promises, or inducements made by either party or agent of
either party which are not contained in this written Agreement shall be valid or
binding. This agreement may not be enlarged, modified, or altered except in
writing, signed by the parties. No change, addition, or erasure of any printed
portion of this Agreement shall be valid or binding upon either party.
SECTION VII: AUDITING, RECORD RETENTION, AND ACCESS TO RECORDS
(1) The Satellite agrees to allow access to the records of the activities
covered by this Agreement to Local Agency, DHES, or as may be necessary for
legislative audit and analysis purposes in determining compliance with the terms
of this Agreement. In addition to the provisions of Section IV, this Agreement
may be terminated upon any refusal of the Satellite to allow the access to
records described above.
(2) Financial records, supporting documents, statistical records, and all
other records supporting the services provided by the Satellite under this
Agreement must be retained for a period of 3 years after the date of submission
of the final statement of reimbursable expenses referred to in Section III. The
Satellite agrees to make the records described herein available at all reason-
able times at its general offices. If any litigation, claim, or audit is
started before the. expiration of the 3-year period, the records must be retained
until all litigation, claims, or audit findings involving the records have been
resolved.
SECTION VIII: SEVERABILITY
It is understood and agreed by the parties hereto that if any term or provision
of this contract is by the courts held to be illegal or in conflict with any
Montana law, the validity of the remaining terms and provisions shall not be
affected, and the rights and obligations of the parties shall be construed and
enforced as if the contract did not contain the particular term or provision
held to be invalid.
SECTION IX: LIAISONS
The Satellite's liaison for purposes of this Agreement is the following person,
or that person's successor.
Name Title
The Local Agency's liaison for purposes of this Agreement is the following
person, or that person's successor.
Name Title
DHES1 liaison to both parties for purposes of this Agreement is the following
person or that person's successor:
Name Title
Appendix 14
Page 4
The parties agree that these persons will be the first contacts concerning any
problems or questions that may arise in the implementation of the terms of this
Agreement.
SECTION XIII: EXECUTION
This Agreement consists of pages and one appendix. The original will be
retained by the Local Agency. A copy of the original has the same force and
effect for all purposes as the original. A copy of the original Agreement will
be sent by the Local Agency to DHES on the day following the Agreement's exe-
cution.
To express the parties' intent to be bound by the terms of this Agreement, they
have executed this document on the dates set out below:
Date Satellite's agent's signature
Print name and title of above
Address of Satellite
Federal Employer's ID No.
Date
s
ignature
of
agent
of
Local
Agen
cy
p
rint name
ar
id tit!
e
of
abo1
ve
Address of Local Agency
Federal Employer's ID No,
Appendix 14
Page 5
APPENDIX 15:
ASSURANCE THAT ADEQUATE FOOD VENDORS SERVE AN AREA
Definitions :
1. Area -- Geographic boundaries of the space generally recognized as being
within the administrative jurisdiction and responsibility of the entity
with which DHES contracts for the operation of the WIC Program.
2. Adequate -- Sufficient number of vendors so that every client has the
choice of two vendors within two hour's transportation of their home, or
if more than 2 hours, then the vendors are within the client's commonly
visited market- basket district.
Assurance
1. Participation in the WIC Program is offered annually to aJN groceries and
dairies in a local agency's area, prior to contract renewals. (Pef.:
Pg. VIII-2 of Manual).
2. The State Agency shall review monthly the "Contracted Vendor File Report"
to determine whether the number of vendors in an area is adequate. This
report is maintained on file at the State Agency.
3. The State Agency will also review the adequacy of vendors in an area at
the time of a local agency evaluation.
4. If the number of vendors is inadequate (as adequate is defined above),
the State Agency will require the Local Agency to justify in writing why
there is not an adequate number of vendors in the area.
5. Within ten working days after receipt of the justification, the State
Agency shall notify the local agency whether or not the State Agency
concurs.
6. If the State Agency does not accept the local agency's justification, the
State Agency shall survey the area's vendors to determine reasons for
non- participation and possible strategies for solutions. If no vendor
is determined to participate within 60 calendar days of the State Agen-
cy's decision in #5 above, then the WIC Program in that area shall be
deemed in non-compliance with Program regulations and terminated immedi-
ately.
3
Appendix 15
Page 1
.
FY 87 AFFIRMATIVE ACTION PLAN
ACTUAL CASELOAD BY PRIORITY FOR MARCH, 1987
A. A.
TOTAL ESTIMATED
%
Proiect
Rank
P-l
P-l I
P-l I I
P-IV
P-V
TOTAL
ELIGIBLE FOR 1988
SERVED
°Yel lowstone
1
363
94
430
53
53
992
3,596
27.59
"Cascade
2
477
86
389
62
132
1,146
3,518
32.58
°Mi ssoul a
3
472
93
726
55
154
1,500
2,404
62.38
"Fort Peck
<l
199
76
462
13
2
752
564
133.29
"Flathead Co.
5
251
40
236
46
1
583
2,102
27.74
"Lewi s & CI ark
6
237
91
268
95
172
863
1,510
57.14
°Cal latin
7
182
38
203
42
29
494
1 ,439
34.32
"Silver Bow
8
212
46
282
38
185
763
996
76.61
+Ravalli
q
116
20
165
21
44
366
1,031
35.51
"Lake
10
121
9
152
4
28
314
1,063
29.53
"Blackfeet
11
215
78
537
17
48
895
652
137.36
"Hill
12
53
26
91
23
67
260
792
32.83
"Lincol n
13
35
34
77
42
33
221
796
27.78
Fergus
14
0
0
0
0
0
0
683
0.00
"Crow
15
158
52
307
28
110
655
648
101 .09
"Richland
16
43
13
62
8
33
159
533
29.84
°N. Cheyenne
17
130
45
216
13
48
452
397
113.72
"Flathead Res.
18
137
32
262
12
30
473
376
125.81
"Valley
20
24
6
18
2
31
81
562
14.42
"Custer
19
75
12
83
5
13
188
473
39.75
+°Rosebud
21
27
13
34
4
8
86
567
15.17
"Bio Horn
22
57
4
98
6
15
180
816
22.05
+°Beaverhead
23
39
8
70
11
54
182
451
40.32
"Dawson
24
45
9
57
12
33
156
400
39.02
+Carbon
25
16
0
18
2
7
43
425
10.13
"Glacier
27
12
3
30
4
12
61
752
8.11
"Sanders
26
59
9
84
6
20
178
381
46.67
+°Blaine
28
11
2
22
4
13
52
508
10.23
+"Park
30
73
5
50
5
25
158
347
45.59
+°Phillips
29
15
10
7
6
37
75
411
18.26
"Teton
31
20
6
22
5
8
61
404
15.08
"Deer Lodge
33
67
26
114
27
87
321
315
102.06
Roosevel t
32
0
0
0
0
0
0
656
0.00
"Pondera
34
14
2
17
1
8
42
373
11.26
"Chouteau
35
14
12
20
1
12
59
341
17.32
+°Powe 1 1
36
35
3
44
5
28
115
308
37.37
"Fort Belknap
37
74
36
111
27
66
314
345
90.99
Toole
38
0
0
0
0
0
0
255
0.00
+"Jef f erson
39
24
9
23
10
17
83
228
36.45
Sheridan
40
0
0
0
0
0
0
251
0.00
Mussel shel 1
41
0
0
0
0
0
0
259
0.00
"Rocky Boy
42
42
30
94
18
52
236
311
75.78
Madi son
43
0
0
0
0
0
0
247
0.00
"Stillwater
44
11
12
31
4
17
75
183
40.95
"Broadwater
45
27
13
33
6
6
85
189
44.95
Sweet Crass
46
9
1
9
11
16
46
182
25.26
"Mineral
47
17
7
21
2
6
53
153
34.75
+°Fallon
48
9
1
9
11
16
46
150
30.69
Judith Basin
49
0
0
0
0
0
0
157
0.00
Daniel s
50
0
0
0
0
0
0
153
0.00
+°McCone
52
1
0
1
0
6
8
149
5.38
+"Powder River
51
4
0
15
1
1
21
140
15.01
Liberty
53
0
0
0
0
0
0
138
0.00
"Granite
55
5
4
14
13
8
44
130
33.84
Wheatland
54
0
0
0
0
0
0
131
0.00
+°Carfield
56
3
2
3
0
0
8
119
6.74
+°Prairie
57
0
0
2
0
2
4
124
3.23
Carter
58
0
0
0
0
0
0
112
0.00
+"Meagher
59
0
0
0
0
0
0
84
0.00
+°Wibaux
60
3
0
0
3
0
6
69
8.69
Golden Valley
61
0
0
0
0
0
0
73
0.00
Treasure
62
0
0
0
0
0
0
57
0.00
Petrol eum
63
0
0
0
0
0
0
56
0.00
)
TOTAL 4,233 1,127
° = Currently operating the WIC Program.
+ = Satellite site
6,019
783
1,793 13,955
36,035
38.73
pi an-3
wi cpl n
■
APPENDIX 16
SUMMARY OF MONTANA WIC FOOD PACKAGES
The WIC food packages, incorporating Montana's tailoring guidelines, are
summarized below:
WIC FOOD PACKAGES
PEANUT
INFANT
INFANT
ADULT
FRESH
POWDERED
BUTTER
FORMULA
CEREAL
JUICE
JUICE
MILK
MILK
ECCS
or BEANS
CEREAL
Infant 0-4 months
31 (13 oz. )
cone, or
8 (1 lb.)
powd. (or
equi v. )
inrant t-lz months
31 (1 3 oz.)
cone, or
8 (1 lb.)
powd. (or
equi v. )
3-6 oz.
boxes
2-12 oz.
frozen
cans
(or
equiv. )
Chi Id - 1 year
6-12 oz.
frozen
cans
(or
equiv. )
2k qts.
No
Reduced
Fat Milk
2 doz.
18 oz. p.
butter
1 cert.
period.
1 lb.
beans
other
36 oz.
1 owest
cost.
Al ternate
hot & cold.
months.
Chi Id - 2-5 years
6-12 oz.
frozen
16 qts.
8 qts.
2 doz.
18 oz. p.
butter
36 oz.
lowest
cans
(or
1 cert.
cost.
period.
Al ternate
equiv. )
1 lb.
beans
other
months.
hot & cold.
Pregnant/'
Breastf eedi ng
6-12 oz.
frozen
cans
(or
equiv. )
20 qts.
8 qts.
2 doz.
18 oz. p.
butter
1 cert.
period.
1 lb.
beans
other
36 oz.
lowest
cost.
■ Alternate
hot & co Id.
months.
Postpartum Woman
4-12 oz.
frozen
cans
(or
16 qts.
8 qts.
2 doz.
36 oz.
lowest
cost.
Alternate
equi v. )
hot & cold.
Speci a I
Dietary
Needs
up to
35 (13
oz.) or
9 (1 lb.)
powd.
w/H.D.
order
3-12 oz.
frozen
cans
(or
equi v. )
36 oz.
(infant
or adult
cereal )
breastf ea
I nf ant
<}S/vg-66d
)
May receive up to 1/2 the maximum amount of formula.
«
I
Rationale for Food Packages
Foods selected by the SA for issuance to WIC participants are detailed in the
State Aqency Approved Food List. These foods are those allowable as specified
in the Federal Regulations, Section 246.10(bHi).
To ensure nutritional integrity, at least one food from each food group in the
standard food package is available to each category of participant.
The CPA has responsibility for making the maximum quantity available based on
the individual's nutritional needs. The CPA has responsibility for adapting the
food package to the needs of participant, i.e., a one vear old requires a lesser
quantity of food than does a four year old.
Food Package I (0-3 Months)
Breastfeeding is encouraged.
If formula is the choice for infant feeding, formula will be iron-fortified
concentrated or powdered. Although powdered formula is generally considered to
be less costly than the concentrated, in some Montana towns it is more expen-
sive. LA's are encouraged to cost compare.
Reduced iron and/or non-iron-fortif ied formula will be issued with a physician's
justification, prescription. Documentation in the client's chart will include
appropriate counseling and follow-up by the CPA.
Soy formula will be issued with a physician's justification and prescription on
a monthly basis. Documentation in the client's chart will include appropriate
counseling and follow-up by the CPA.
Ready-to-feed formula may be issued when the CPA determines and documents that
there is unsanitary or restricted water supply, poor refrigeration, or that the
infant's caretaker may have difficulty in correctly preparing the powdered or
concentrated formulas.
Cow or goat milk will not be issued to infants.
Food Package II (4-12 Months)
Breastfeeding will be encouraged.
Frozen juice concentrate will be issued except when the CPA determines and
documents that there is an unsanitary or restricted water supply, poor refrig-
eration, or that the infant's caretaker may have difficulty in correctly prepar-
ing the concentrated juice. y
No infant juice will be issued.
and'usTngVcu ^ ^^ t0 *" '"^ UPtil he/She iS 3t leaSt 6 months of a9e
Sptln-branHH !!nd St,°re b:ands of autn°rized juice that are 100% juice, have
sweetening added, and supply 100% vitamin C may be issued.
PH/war-5pln-l
no
Cow and goat milk will not be issued to infants.
LA's are encouraged to keep price lists current, and as part of the nutrition
education of the client, offer the lower cost choices.
Food Package III (Children/Women with Special Dietary Needs)
Special dietary needs of children and women may require supplemental foods. If
the physician determines the need for formula for a child or woman (i.e., soy),
the specific formula prescribed and the prescription order from the physician
must be included in the participant's file. Appropriate counseling and fol-
low-up must also be documented in the client's file by the CPA.
The quantities and types of supplemental foods prescribed shall be appropriate
for the participant, taking into consideration the age and special dietary needs
of the participant. The maximum Quantities of supplemental foods authorized per
month will not exceed the maximum allowable amounts as in CFR 246. 9(3) (iv) .
Food Package IV (Children 1 to 5 Years)
Pasteurized whole, low fat, skim, dry powdered, and evaporated milk, which are
appropriately fortified with vitamins D and A are the milk choices and may be
issued to a 24 quart maximum. A portion of the allowed quantity will be dry
powdered milk.
Low fat milk is not authorized for children under two years of age. (Fomon, SJ,
Siegler, E.E., Nelson, S.E., and Edwards, B.B.)
Authorized hot and cold cereals up to a maximum of 36 oz (dry).
Authorized juice up to a maximum of 288 fluid oz. reconstituted.
Eggs: Two dozen large AA.
Cheese will not be issued.
Cheese is provided by the Surplus Commodity Program which is available in
all the WIC clinic sites.
Peanut butter, any brand that does not contain jelly, honey, or other sweetener,
may be issued once in a certification period and may not exceed 18 oz.
Dried peas, beans, or legumes, one pound maximum, may be offered the months
peanut butter is not issued.
Food Package V (Pregnant and Breastfeeding Women)
28 quarts of milk with a portion of it dry, powdered milk.
36 oz. cold or dry authorized cereal.
192 fluid oz. reconstituted concentrated authorized juice.
PH/war-5pln-2
The breastfeeding woman who supplements her infant's diet with formula may
receive a full food package.
CPA's should counsel appropriately to encourage breastfeeding and should esti-
mate the infant's intake from breastfeeding and adjust the supplemental formula
in the infant package accordingly. The infant may receive up to 1/2 of the
maximum amount of formula.
PH/war-5pln
PH/war-5pln-3
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